Strategie di Prevenzione del Rischio CCV Globale. La diagnosi pre-clinica della disfunzione ventricolare sinistra

Transcription

1 Strategie di Prevenzione del Rischio CCV Globale 1^ edizione: 13 novembre 2010 ore SALA CARAVAGGIO - FIERA DI BERGAMO Via Lunga BERGAMO Per i MAP dei distretti di: Seriate Grumello Valle Cavallina Basso Sebino Alto Sebino Valle Imagna Valle Brembana - Isola Bergamasca II sessione: Interventi nella fase pre-clinica La diagnosi pre-clinica della disfunzione ventricolare sinistra Antonello Gavazzi Dipartimento Cardiovascolare Clinico e di Ricerca SC di Cardiologia Dipartimento Cardiovascolare Ospedali Riuniti - Bergamo Ospedali Riuniti Bergamo

2 How Can We Decrease the Prevalence of CHF Soon? Incidence CHF Survival Population Demographics

3 Heart Failure: Incidence Aging of the population Decrease AMI fatality Increase Diabetes inc. Incidence Prevention of CAD Treatment of HTN Thrombolytic/PTCA Tx in AMI ACE-i/ i/beta-blockersblockers Incidence

4 ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult.

5 The Epidemiology of Asymptomatic Left Ventricular Systolic Dysfunction: Implications for Screening. Wang et al. Ann Intern Med. 2003;138: Prevalence of Left Ventricular Systolic Dysfunction by EF Threshold

6 Screening for Left Ventricular Systolic Dysfunction among patients with Risk Factors for Heart Failure Visual estimates of LVEF were recorded in 5-percentage-point increments Based on visual estimation of LVEF from Echo. The difference in prevalence of LVEF < 0.45 across all groups was significant at P.025. Baker et al. Am Heart J 2003;146:736 40

7 Association of Systolic Dysfunction With Cardiovascular Disease Redfield et al. JAMA 2003;289:

8 Prevalence of Systolic and Diastolic Dysfunction According to Age and Sex Redfield et al. JAMA 2003;289:

9 Natural History of Asymptomatic LV Dysfunction Community-based Studies - Increased CV Mortality Rates - Increased all-cause Mortality - Increased nonfatal CV Events Placebo Group of 5 RCTs (> pts: ANZC1990, SAVE1992, SOLVD 1992,TRACE 1995, Dofetilide, 2000) - Average Annual CHF Rates: 4,9-20% - Average Annual Mortality Rates: 5,1-10,5%

10 Use of Evidence-based Therapies to prevent HF among patients with LVEF 0.45 and > 0.45 Baker et al. Am Heart J 2003;146:736 40

11 ASYMPTOMATIC LV DYSFUNCTION SCREENING STRATEGIES ECHOCARDIOGRAPHY (gold-standard) ECG BNP / NTproBNP

12 Accuracy of BNP (cut-off 17.9 pg/ml) in detection of LV Systolic Dysfunction Group Sensibility Specificity PPV NPV Prevalence (%) (%) (%) (%) of LVD (%) Partecipants aged All With IHD Partecipants aged >55 All With IHD McDonagh T et al. Lancet 1998

13 Asymptomatic LV Systolic Dysfunction People > 55 years with Ischaemic Heart Disease 100 BNP Sensitivity 50 N-ANP Specificity AUC Other Screening Tests Area Under Curve McDonagh T et al. Lancet 1998 PSA 0.94 BNP 0.88 Mammography 0.85 Cervical Smears 0.70

14 Diagnostic Value of BNP in Relation to Risk Group NNE Number of subjects Needed to be Examined to detect one case of LVSD Price and Cost-Effectiveness of BNP Compared With Echocardiogram in Relation to Risk Group Nielsen et al. J Am Coll Cardiol 2003;41:

15 ECG and BNP as screening tools for LVSD in a population-based sample of 75-year-old men and women. Conclusions Both the ECG and the BNP are highly efficient in excluding LVSD. In screening for LVSD, the BNP has a diagnostic value in addition to the ECG, but only in individuals with abnormal ECGs. Hedberg et al. Am Heart J 2004;148:524 9.

16 Therefore, measurement of NTproBNP is a better investigation in primary care than ECG for the detection of significant LVSD. Lim et al. International Journal of Cardiology 2007;115:73-74.

17 What is the most cost-effective strategy to screen for LV Systolic Dysfunction? Galasko et al. Eur Heart J 2006;27: Prevalence of LVSD 3,5% in General population 0,2% in Low-risk group 8,5% in High-risk group

18 What is the most cost-effective strategy to screen for LV Systolic Dysfunction? Galasko et al. Eur Heart J 2006;27: SCREENING STRATEGIES ASSESSED Strategy 1. Traditional Echocardiogram (TE), gold-standard strategy. Strategy 2. ECG. If abnormal ECG TE. Strategy 3. NTproBNP. If raised levels TE. Strategy 4. ECG + NTproBNP. If either test abnormal TE. Strategy 5. ECG + NTproBNP. If both tests abnormal TE. Strategy 6. Hand-held Echocardiogram (HE). If LVSD on visual inspection TE. Strategy 7. ECG. If abnormal ECG HE. If LVSD on visual inspection TE. Strategy 8. NTproBNP. If raised levels HE. If LVSD on visual inspection TE.

19 What is the most cost-effective strategy to screen for LV Systolic Dysfunction? Galasko et al. Eur Heart J 2006;27: Conclusions This study supports screening high-risk subjects only (those with one or more risk factor for LVSD), as this would be most cost-effective while missing few community cases of LVSD. The ECG, the NTproBNP, and HE can all be used cost-effectively for screening, with the most cost-effective strategy of all being BNP or ECG pre-screening prior to HE prior to formal TE.

20 ASYMPTOMATIC LV DYSFUNCTION Cost-effectiveness of early detection and treatment CONCLUSIONS The most cost-effective strategy is screening high-risk subjects only (those with 1 risk factor for LVD) The ECG, the BNP and the Echocardiography have all a diagnostic value and strategies combining these tests can all provide a health benefit at a cost that is comparable to or less than other accepted health interventions. More extensive programs of population screening are needed (CHF prevention).

21 Dipartimento Cardiovascolare Clinico e di Ricerca Ospedali Riuniti Bergamo ALVSD (SYSTOLIC) ALVDD (DIASTOLIC) Grosu A et al. Eur J Heart Fail 2010;9(Suppl 1):S153-S154.

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23 Dipartimento Cardiovascolare Clinico e di Ricerca Ospedali Riuniti Bergamo n = 51 (8.5%) ALVSD (SYSTOLIC) n = 522 ALVDD (DIASTOLIC) Gori M et al. Eur Heart J 2010; 31 (abstract Supplement):

24 Prevalence of Asymptomatic Left Ventricular Diastolic Dysfunction (ALVDD) Study OLMSTED C. Redfield (2003) PROBE (2010) Luers (2010) OLMSTED C. From (2010) DAVID-Berg (2010) Setting Community Diabetes/HT High Risk Diabetes High Risk N ALVDD Prevalence - Mild - Moderate - Severe All 20.8% 6.6% 0.7% 28.1% 32,4% } 4,4% 36.8% 54% 8.3% 2.7% 65% 23% 12.9% 21% Diastolic Dysfunct. Criteria - Mild - Moderate E/A ratio < 0.8 and DT >240ms E/A ratio >0.8 and <1.5 DT 160 to 240ms changing with Valsalva E/A<1; EDCT>280 ms IVRT>105ms; S/D>1 Ea<8cm/s; Vp<45 cm/s 1<E/A>2 150<EDCT>200ms 60<IVRT>105ms S/D<1 Ea<8cm/s Vp<45cm/s Septal E' wave <8cm/sec and LAVI 34ml/m 2 - Severe E/A ratio >1.5 DT <150ms E/A >2 or E/Ea >15 and LAD >45mm E/e ratio >15 E/e ratio >15

25 Kaplan-Meier Analysis of Diastolic Dysfunction and Mortality or Subsequent HF developement in Diabetic Patients ALVDD (E/e >15) prevalence = 23% Diastolic dysfunction defined as passive transmitral LV inflow velocity to TDI velocity of the medial mitral annulus during passive filling (E/e ) ratio > 15 From AM et al. J Am Coll Cardiol 2010;55:300 5

26 Practice Population Dipartimento Cardiovascolare Clinico e di Ricerca Ospedali Riuniti Bergamo > 55 < 80 yrs DAVID-Berg n = > 1 CV risk factor n = Echo not evaluable: n = 6 - Severe Valvul. disease : n = 27 EF 45% n = AF - PM - LVEDVI 91 - LVEF < 45% n = 544 EF < 45% E/e > 15 n = 570 NORMAL SYSTOLIC LEFT VENTRICULAR FUNCTION n = 17 (2,9%) n = 70 (12,9%) ALVSD (SYSTOLIC) ALVDD (DIASTOLIC)

27 DAVID-Berg Dipartimento Cardiovascolare Clinico e di Ricerca Ospedali Riuniti Bergamo ALV SYSTOLIC DYSFUNCTION Prevalence (EF < 45%): 2,9% EF 45% EF < 45% P n= 570 n= 17 - Male gender 56% 82% Alcohol 65% 100 % Hypertension 89% 71% Ischemic heart disease 31% 82% Previous MI 18% 80% Previous CABG 4% 38% Atrial fibrillation 3% 18% LBBB 3% 18% Pathologic Q waves 13% 71% ST-T changes 47% 94% Any abnormal ECG 51% 84% QRS duration (ms) 96 ± ± NT-proBNP (pg/ml) 295 ± ±

28 DAVID-Berg Dipartimento Cardiovascolare Clinico e di Ricerca Ospedali Riuniti Bergamo Asymptomatic LV Systolic Dysfunction LVEF: n=587, median 60%[55-65] NT-proBNP (pg/ml) median [Q1-Q3] 1212 [ ] N = 17 (2,9%) LVEF < 45% p<0, [87-309] N = 570 (97,1%) LVEF 45% 50% > 50%

29 DAVID-Berg Dipartimento Cardiovascolare Clinico e di Ricerca Ospedali Riuniti Bergamo ALV DIASTOLIC DYSFUNCTION Prevalence (E/e > 15) 12,9% E/e 15 E/e > 15 P n= 474 n= 70 - Female gender 42% 64% Age (years) 69 ±7 71 ± Systolic BP (mm Hg) 151 ± ± LBBB 2% 6% LV Hypertrophy (ECG) 4% 8% NT-proBNP (pg/ml) 232 ± ±

30 DAVID-Berg Dipartimento Cardiovascolare Clinico e di Ricerca Ospedali Riuniti Bergamo Asymptomatic LV Diastolic Dysfunction 700 NT-proBNP (pg/ml) median [Q1-Q3] [ ] N = 70 (12,9%) E/e > 15 p<0, [79-293] N = 474 (87,1%) E/e 15 >15 <15

31 DAVID-Berg Dipartimento Cardiovascolare Clinico e di Ricerca Ospedali Riuniti Bergamo NEGATIVE PREDICTIVE VALUE All Male Female 70yrs >70yrs ALV SYSTOLIC DYSFUNCTION ECG (Pathol Q + DQRS >110 ms) NT-pro BNP < 200 pg/ml ALV DIASTOLIC DYSFUNCTION NT-pro BNP < 180 pg/ml

32 DAVID-Berg Dipartimento Cardiovascolare Clinico e di Ricerca Ospedali Riuniti Bergamo Conclusions In the population examined at high cardiovascular risk The Asymptomatic LV Systolic Dysfunction is quiet common (prevalence( 2,9-8,5%) The Asymptomatic LV Diastolic Dysfunction has a higher prevalence (12,9-21%) 21%) The ALVD is significantly associated with higher levels of NT-proBNP ( negative predictive value) These results suggest that the screening programs in this type of population are appropriate and should be more extensively implemented

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