La ricerca nello scompenso cardiaco acuto: ci sono reali novit

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La ricerca nello scompenso cardiaco acuto ci
sono reali novità?
Aldo P Maggioni Centro Studi ANMCO Firenze
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Lepidemiologia dello scompenso acuto rimane un
problema rilevante senza segni di miglioramento
nel tempo
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AHF vs CHF outcomes
Lee DS, Am. J. Med. 2004
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La ricerca sui trattamenti dello scompenso
cardiaco acuto

• Fallimenti
• Semidelusioni
• Piccoli successi

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Sopravvivenza dei farmaci per lo S.C. grave
Xamoterolo
Milrinone
(PROMISE)
Vesnarinone
(VEST)
Ibopamina
(PRIME-2)
Pimobendan
Epoprostenol
(First)
Bosentan
(REACH-1)
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La ricerca sui trattamenti dello scompenso
cardiaco acuto

• Fallimenti
• Semidelusioni

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A. Mebazaa et al., JAMA 2007, 297 1883-1891
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BNP
A. Mebazaa et al., JAMA 2007, 297 1883-1891
A. Mebazaa et al., JAMA 2007, 297 1883-1891
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A. Mebazaa et al., JAMA 2007, 297 1883-1891
A. Mebazaa et al., JAMA 2007, 297 1883-1891
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La ricerca sui trattamenti dello scompenso
cardiaco acuto

• Fallimenti
• Semidelusioni
• Piccoli successi

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M.A. Konstam et al., JAMA 2007, 297 1319-1331
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M.A. Konstam et al., JAMA 2007, 297 1319-1331
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• Per cominciare a ragionare più seriamente
• E possibile fare una stratificazione dei rischi
  affidabile ?

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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

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EHFS II All-Cause in-Hospital Mortality
39.6
6.6
5.3
5.4
n. 3580 pts
n. 139 pts
n. 2202 pts
n. 1239 pts
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Univariate analysis in-hospital mortality by
age, SBP and creatinine at hospital entry
12.9
(n. 3441 patients)
10.8
9.3
6.4
5.7
5.1
3.4
3.4
3.0
lt65
65-80
gt80
gt130
110-130
lt110
lt1.4
1.4-2.0
gt2.0
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EHFS II All-cause in-hospital mortality by
strata of risk score
Risk score
743
772
726
574
305
321
N. of pts
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• Per cominciare a ragionare più seriamente
• E possibile fare una stratificazione dei rischi
  affidabile ?
• Quali end-point e a quali tempi dobbiamo
  misurarli ?

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All-cause mortality The lessons learned from
trials and registries...
Chronic HF
ACS
Acute HF
Opasich C et al. for the IN-CHF Investigators. Am
J Cardiol 2000 86 353-357 GISSI-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
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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

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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 Mortality
• Reduce Morbidity (worsening heart failure?)
• Rapid and safe symptoms relief
• Or in other words everything

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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