La ricerca nello scompenso cardiaco acuto: ci sono reali

novità?

Aldo P MaggioniCentro Studi ANMCO

Firenze

L’epidemiologia dello scompenso acuto rimane un

problema rilevante senza segni di miglioramento nel

tempo

AHF vs CHF outcomes

Lee DS, Lee DS, Am. J. Med. 2004Am. J. Med. 2004

La ricerca sui trattamenti dello scompenso cardiaco acuto

Fallimenti Semidelusioni Piccoli successi

Sopravvivenza dei farmaci per lo S.C. grave

Xamoterolo

1990 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 1998

Milrinone(PROMISE)

Vesnarinone(VEST)

Ibopamina(PRIME-2)

Pimobendan

FlosequinonEpoprostenol

Bosentan(First)

(REACH-1)

La ricerca sui trattamenti dello scompenso cardiaco acuto

Fallimenti Semidelusioni

Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007

Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007

A. Mebazaa et al., JAMA 2007, 297: 1883-1891

Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007

A. Mebazaa et al., JAMA 2007, 297: 1883-1891

BNP

A. Mebazaa et al., JAMA 2007, 297: 1883-1891

Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007A. Mebazaa et al., JAMA 2007, 297: 1883-1891

A. Mebazaa et al., JAMA 2007, 297: 1883-1891

La ricerca sui trattamenti dello scompenso cardiaco acuto

Fallimenti Semidelusioni Piccoli successi

M.A. Konstam et al., JAMA 2007, 297: 1319-1331

M.A. Konstam et al., JAMA 2007, 297: 1319-1331

Per cominciare a ragionare più seriamente

E’ possibile fare una stratificazione dei rischi affidabile ?

Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007

EHS HF II: data collection

Patients screened at the emergency area, including cardiac care unit (CCU) or intensive care unit (ICU), as well as on ward facilities (internal medicine or cardiology)

133 participating hospitals: university hospitals (47%) community or district hospitals (49%) private clinics (4%)

30 European countries Recruitment from 21 October 2004 until 31 August

2005

Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007

EHFS II: All-Cause in-Hospital Mortality

6.6%

39.6%

5.3% 5.4%

n. 3580 pts n. 139 pts n. 2202 pts n. 1239 pts

Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007

Univariate analysis: in-hospital mortality by age, SBP and creatinine at hospital entry

<65 65-80 >80 >130 110-130 <110 <1.4 1.4-2.0 >2.0

3.0%

5.1%

9.3%

3.4%

5.7%

10.8%

3.4%

6.4%

12.9%

(n. 3441 patients)

Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007

Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007

EHFS II: All-cause in-hospital mortalityby strata of risk score

Risk score

N. of pts 772 743 726 574 305 321

1-Specificity

0,0 0,2 0,4 0,6 0,8 1,0

Se

nsi

tivity

0,0

0,2

0,4

0,6

0,8

1,0

AUC = 0.781

Per cominciare a ragionare più seriamente

E’ possibile fare una stratificazione dei rischi affidabile ?

Quali end-point e a quali tempi dobbiamo misurarli ?

Euro Heart Survey - ESC congress, Vienna, September 2007Euro Heart Survey - ESC congress, Vienna, September 2007

Chronic HF

ACS

All-cause mortality:The lessons learned from trials and registries...

Acute HF

Opasich C et al. for the IN-CHF Investigators. Am J Cardiol 2000; 86: 353-357GISSI-3: Six-month data. J Am Coll Cardiol 1996; 27: 337-344

Tavazzi L et al. The Italian survey on Acute Heart Failure. Eur Heart J 2006; 27: 1207-1215

Research in acute HF: Conclusions

Morbidity and mortality of patients with acute HF remain unacceptably high

Treatment of acute HF continues to remain largely anecdotal without much progress in the last decades

Risk stratification with the identification of simple clinical variables seems to be feasible in any clinical setting

In any case, the application of risk scores in the real world of acute HF could be limited by: The heterogeneity of this clinical condition The different patho-physiological background The various clinical settings (and doctor profiles) in which patients with AHF

are managed Further efforts should be focused on planning research in the

field of AHF

What do we need ?

Data on the clinical characteristics. Definition, sub-clasification (ST/non-ST ) Data on the exact pathophysiology of each

subtype. Better ways to risk-stratify the patients. Treatments to:

Reduce MortalityReduce Morbidity (worsening heart failure?)Rapid and safe symptoms relief

Or in other words … everything…

Comparison of decompensated heart failure with acute myocardial infarction

Decompensated Acute myocardial Heart failure infarction

Hospitalization per year(in US) 1,000,000 1,000,000

In-Hospital Mortality 3-12% 3-7%

Readmission rate (60 days) 35% 10%

Guidelines for risk stratification No Yes

Guidelines for therapy Yes (ESC) Yes

No (AHA/ACC)

Largest randomized trial 4,133 41,021

MEDLINE citations (1965-2006) 472 33,908

Modified from Am Heart J 2003; 145: S18-25