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Prevenire lo scompenso e le sue recidive

La terapia non

farmacologica

Sessione II - Prevenzione, Terapia,

Riabilitazione dello Scompenso

Cardiaco


La terapia non farmacologica dello scompenso cardiaco

cronico consiste nell’attuazione di misure strumentali

invasive e/o propriamente chirurgiche per il trattamento dei

casi refrattari alla terapia medica condotta in modo ottimale e

appropriato

Le procedure oggi attuate sono:

•Terapia elettrica (ICD, CRT-P, CRT-D)

•Ultrafiltrazione

•Terapia invasiva percutanea

•Terapia chirurgica

Terapia non farmacologica; Classificazione:


Terapia Elettrica

Terapia non farmacologica;

Morte improvvisa nello

scompenso cardiaco

Cardiomiopatia ischemica Meissner MD Circulation 1991; 84:905-912

95%

5%

Scompenso cardiaco severo

Stevenson WG Circulation 1993; 88:2953-2961

Scompenso cardiaco

Uretsky BF JACC 1997; 30: 1589-1597

30%

62%

8%

25%

20%50%

5%

bradi

VT/VF

VTmono

altre


Sudden death accounts

for ~ 50% of mortality in

advanced HF


0

5

10

15

20

25

30

35

40

NYHA I II III IV

% 1

ye

ar

mo

rta

lity

morte improvvisa mortalità totale

SOLVD-Pre

DIG 1996

SOLVD-Treat

V-HeFT II

ELITE 1997

CARVEDILOL

UCLA

VESNARINONE

CONSENSUS

Stevenson WG. J Cardiovasc. Electrophysiol. 2001; 21:112-4

Morte improvvisa nei trials sullo scompenso cardiaco


Risk of SCD in post-MI

Mortality risk in contemporary post-MI patients with EF ≤ 30% tends to increase as a function of time from last MI

Wilber D et al. Circulation 2004;109:1082-84


Mortalità e disfunzione

VS nel post-infarto

0

10

20

30

40

50

mo

rta

lità

1 anno 5 anni

morte improvvisa mortalità totale

Tavazzi L Circulation 1997; 95: 1341-1345


Morte improvvisa nella

miocardiopatia dilatativa

0123456789

10

n. even

t/1

00

pz/an

no

0-60 61-120mesi

mortalità totale morte scompenso o trap.

morte imp. morte imp. 3 mesi

3

mesi

Di Lenarda A Circulation 1998; 98: (suppl I): I-507


ICD: trials di prevenzione

secondaria della morte

improvvisa

AVID CIDS CASH Target VT/VF VT/VF VF

Trattamento ICD vs drug ICD vs amio ICD vs drug

N.pz 1016 659 349

CHF 58% 50% 73%

NYHA II 48% 38% 57%

NYHA III 10% 10%(+IV) 16%

NYHA IV esclusi 10%(+III) esclusi

FE media 31-32% 33-34% 44%

CAD 81% 76% 75%

<RR mortalità 39% 20% 38%


Effectiveness of ICDs in Preventing SD

A Meta Analysis – Secondary Prevention

Lee DS: J Am Coll Cardiol 2003; 41: 1573

Absolute Reduction = 7%

Number Need to Treat = 15

Prevenzione secondaria:

con ICD - metanalisi


ACC Heart Failure Guidelines

Based on the 2009 Focused Update Incorporated Into the

ACCF/AHA 2005 guidelines for the Diagnosis and Management

of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart

Association Task Force on Practice Guidelines

Developed in Collaboration With: International Society for Heart and Lung Transplantation

Jessup M. JACC 53, n. 15, 2009: 1343-1382

Patients With Reduced Left

Ventricular Ejection Fraction

A cardioverter-defibrillator (ICD) is recommended as secondary prevention to prolong survival in patients with current or prior symptoms of HF and reduced LVEF who have a history of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular tachycardia. NO CHANGE

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Secondary Prevention: Implantable Cardioverter-Defibrillator

Jessup M. JACC 53, n. 15, 2009: 1343-1382

ACC/AHA/HRS 2008 Guidelines

for Device-Based Therapy

of Cardiac Rhythm Abnormalities

Epstein A. JACC 51, 21, 2008: 2085-2105

Implantable Cardioverter-Defibrillators

secondary prevention

ICD indicated in survivors of cardiac arrest due to

ventricular fibrillation or hemodynamically unstable

sustained VT, after defining the cause of the event and

to excluding completely reversible causes.

ICD indicated in patients with structural heart disease

and spontaneous sustained VT, whether

hemodynamically stable or unstable.

ICD indicated in patients with syncope of undetermined

origin with clinically relevant, hemodynamically

significant sustained VT or VF induced at

electrophysiological study.

I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III I I I IIa IIa IIa IIb IIb IIb III III III IIa IIa IIa IIb IIb IIb III III III



ACC/AHA/HRS 2008 Epstein A. JACC 51, 21, 2008: 2085-2105

Incidenza morte

improvvisa e totale eventi

Percentuale/anno

0 1 2 5 10 20 30

Incidenza totale in

popolazione adulta

Sottogruppo ad alto

rischio coronarico

Qualsiasi evento

coronarico primario

Scompenso

E.F. < 30%

Sopravvissuti ad

arresto cardiaco

extra-ospedaliero

Pregresso I.M.

TV/FV

Eventi/anno

0 100 200 300

x 1000

Myerburg RJ J Cardiovasc Electrophysiol 2001; 12:369-381

MADIT -MUSTT

AVID-CIDS-CASH

SCD-HeFT COMPANION

MADIT 2 MADIT-CRT


HF in Primary Prevention

Morbidity/Mortality Trials

NYHA

FE

I

II

III

IV

<30% <35%

NYHA

FE

I

II

III

IV

<30% <35%

IDIOPATHIC POST-MI

MADIT II (ICD) COMPANION (PM / ICD BiV) DEFINITE (ICD) SCD-HeFT (ICD)

©JM


Nanthakumar K. J Am Coll Cardiol 2004; 44: 2166-72

Absolute Reduction = 8%

Number Need to Treat = 12

Prevenzione primaria:

metanalisi




ICD is recommended for primary prevention of sudden cardiac death to reduce total mortality in patients with nonischemic dilated cardiomyopathy or ischemic heart disease at least 40 days post-

myocardial infarction, LVEF ≤ 35%, NYHA II – III with optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year.

Modified


Primary Prevention: Implantable Cardioverter-Defibrillator

Jessup M. JACC 53, 15, 2009: 1343-1382

ICD indicated in patients with LVEF < 35% due to prior MI who are at least 40 days post-MI and are in NYHA II or III.

ICD indicated in patients with LV dysfunction due to

prior MI who are at least 40 days post-MI, have LVEF < 30%, and are in NYHA I.

ICD indicated in patients with nonsustained VT due to

prior MI, LVEF < 40%, and inducible VF or sustained VT at electrophysiological study.




All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.


primary prevention post-MI


ICD indicated in patients with nonischemic DCM who have an LVEF ≤ 35% and who are in NYHA II or III.

ICD is reasonable for patients with unexplained

syncope, significant LV dysfunction, and nonischemic DCM.




primary prevention non ischemic DCM


I IIa IIb III

ICD is reasonable for nonhospitalized patients awaiting transplantation.

ICD is reasonable for patients with cardiac sarcoidosis, giant cell myocarditis, or Chagas disease.


I IIa IIb III

I IIa IIb III



ICD mortality reductions in primary prevention trials are equal

to or greater than those in secondary prevention trials.

37%

20%

54%60%

31%

41%

23%

36%

31%

0%

10%

20%

30%

40%

50%

60%

AVID

3

Years

CASH

2

years CIDS

3

years

MADIT

2

years MUSTT

5 years

Mo

rtali

ty R

ed

ucti

on

(%

)

MADIT II

3 years

Secondary

Prevention

Primary

Prevention

SCD-HeFT

5 years DEFINITE

3 years

COMPANION

1 years

Mortality reductions

with ICDs


Sintomi di Scompenso Cardiaco + Ridotta Frazione d’Eiezione

Diuretico + ACE-I + ß-bloccante titolati alla stabilità clinica

Persistenza di segni e sintomi?

QRS>120 ms?

si

Considerare: CRT-P or CRT-D

Considerare: Digossina, idralazina/nitrati,

LVAD, trapianto

Aggiungere antagonista dell’aldosterone o ARB

Persistenza di segni e sintomi? no

si no

LVEF<35%?

si no

Considerare: ICD

Nessun ulteriore trattamento

si no

Strategy for use of drugs and devices in

symptomatic HF and systolic dysfunction

Dickstein K European Heart Journal 2008, 29: 2388-2442

Trials randomizzati hanno dimostrato nei paz.

con HF un significativo beneficio indotto

dall’ICD nella sopravvivenza libera da morte

improvvisa, sia in prevenzione primaria che

secondaria

Conclusioni


La terapia di

resincronizzazione

cardiaca


Elements of Cardiac Dyssynchrony

Atrio-

ventricular

Inter-

ventricular

Intra-

ventricular

Cazeau, et al. PACE 2003; 26[Pt. II]: 137–143

• riduce il tempo di riempimento diastolico

• prolunga il tempo di contrazione

• prolunga il rigurgito mitralico

• contrazione sistolica settale precoce

• dissinergia movimento parietale

• Intraventricular Activation • Organized ventricular

activation sequence • Coordinated septal and

free-wall contraction • Improved pumping

efficiency

Issues associated with heart failure

Mechanism II–ventricular resynchronization

Sinus node

AV node

Stimulation therapy

Conduction block

ACC Heart Failure Guidelines

Based on the 2009 Focused Update Incorporated Into the

ACCF/AHA 2005 guidelines for the Diagnosis and Management

of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart

Association Task Force on Practice Guidelines

Developed in Collaboration With: International Society for Heart and Lung Transplantation

Jessup M. JACC 53, 15, 2009: 1343-1382



HF patients with LVEF ≤ 35%, sinus rhythm, and NYHA III – IV despite optimal medical therapy and who have cardiac dyssynchrony, as defined by QRS duration ≥ 120 ms should receive cardiac resynchronization therapy, with or without an ICD, unless contraindicated.


Resynchronization Therapy

Jessup M. JACC 53, 15, 2009: 1343-1382

Sintomi di Scompenso Cardiaco + Ridotta Frazione d’Eiezione

Diuretico + ACE-I + ß-bloccante titolati alla stabilità clinica

Persistenza di segni e sintomi?

QRS>120 ms?

si

Considerare: CRT-P or CRT-D

Considerare: Digossina, idralazina/nitrati,

LVAD, trapianto

Aggiungere antagonista dell’aldosterone o ARB

Persistenza di segni e sintomi? no

si no

LVEF<35%?

si no

Considerare: ICD

Nessun ulteriore trattamento

si no

Treatment strategy for the use of drugs and devices in patients with symptomatic HF and systolic dysfunction

Dickstein K European Heart Journal 2008, 29: 2388-2442

ACC/AHA/HRS 2008 Guidelines

for Device-Based Therapy

of Cardiac Rhythm Abnormalities

May 2008

Cardiac Resynchronization Therapy* in

Patients With Severe Systolic Heart Failure

For patients with LVEF ≤ 35%, QRS duration ≥ 120 ms and sinus rhythm, CRT with or without ICD is indicated for the treatment of NYHA III - IV heart failure symptoms on optimal recommended medical therapy.

*All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

I IIaIIbIII

Cardiac Resynchronization Therapy* in Patients

With Severe Systolic Heart Failure

For HF patients with NYHA III - IV on optimal medical therapy, LVEF ≤ 35%, QRS duration ≥ 120 ms and AF, CRT with or without an ICD is reasonable

For HF patients with NYHA III - IV on optimal medical therapy, LVEF ≤ 35% and frequent dependence on ventricular pacing, CRT is reasonable.

For HF patients with NYHA I - II on optimal medical therapy, LVEF ≤ 35% and who are undergoing implantation of permanent PM and/or ICD with anticipated frequent ventricular pacing, CRT may be considered.

I IIa IIb III




Jessup M. JACC 53, 15, 2009: 1343-1382

Cardiac Resynchronization Therapy* in

Patients With Severe Systolic Heart Failure

CRT is not indicated for asymptomatic patients with reduced LVEF in the absence of other indications for pacing.

CRT is not indicated for patients whose

functional status and life expectancy are limited predominantly by chronic noncardiac conditions.



*All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation of survival with good functional capacity for more than 1 year.

Trials randomizzati hanno dimostrato lo ICD riduce la

morte improvvisa nello HF, sia in prevenzione primaria

che secondaria

Trials randomizzati in paz. con HF in classe NYHA III–

IV hanno dimostrato una riduzione di eventi fatali e

non fatali con la CRT, con o senza ICD.

Trials randomizzati in paz. con HF in classe NYHA II

hanno dimostrato un beneficio della CRT, con o

senza ICD, sulla progressione di malattia e sulla

morbosità.

Conclusioni Prevenire lo scompenso e le sue recidive


L’ultrafiltrazione utilizza apparecchiature assai simili a quelle

usate per l’emodialisi; Il sangue passa in un circuito veno-

venoso o artero-arterioso dove una membrana

semiperrmeabile filtrante lascia passare l’acqua e i soluti con

un peso molecolare inferiore ai 50000 Dalton;

•Deve essere presa in considerazione in pazienti selezionati con sovraccarico idrico (edema periferico e/o polmonare) e per correggere l’iponatriemia nei pazienti sintomatici refrattari alla terapia diuretica;

•Raccomandazione di Classe II a, livello di evidenza B

Ultrafiltrazione


Rivascolarizzazione tramite PTCA (nelle forme ischemiche)

Utilizzo di dispositivi di assistenza ventricolare sinistra

(LVAD): le attuali indicazioni ne prevedono l’uso come

soluzione di ponte al trapianto in presenza di una miocardite

severa (Raccomandazione di Classe II a, Livello di evidenza C)

Terapia invasiva percutanea


•

•Chirurgia coronarica

•Chirurgia valvolare

•Aneurismectomia ventricolare sinistra

•Trapianto cardiaco

Terapia chirurgica

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