LO SCOMPENSO CARDIACO CRONICO DOMANI

Transcription

1 LO SCOMPENSO CARDIACO CRONICO DOMANI Dott. Marco Canepa Ricercatore Cardiologo Malattie dell Apparato Cardiovascolare Università degli Studi di Genova Ospedale Policlinico San Martino, Genova

2 LO SCOMPENSO CARDIACO CRONICO DOMANI DISCLOSURE INFORMATION Marco Canepa negli ultimi due anni ho avuto i seguenti rapporti anche di finanziamento con soggetti portatori di interessi commerciali in campo sanitario: Novartis, BMS Pfizer, Vifor Pharma, Daiichi Sankyo

3 LO SCOMPENSO CARDIACO CRONICO DOMANI Domani è un altro giorno e si vedrà ( ghe pensiemmu ) Domani un altro giorno arriverà Domani un altro giorno ormai è qua!

4 TOMORROW HOSPITALIZATIONS DEATH

5 HOSPITALIZATIONS

6 HOSPITALIZATIONS Maggioni AP et al. ARNO registry. EUR J HEART FAILURE 2016

7 TOMORROW S SOLUTIONS TODAY DIAGNOSTIC x3 THERAPEUTIC x1 PROGNOSTIC

8 HOSPITALIZATIONS Maggioni AP et al. ARNO registry. EUR J HEART FAILURE 2016

9 FLUID OVERLOAD

10 HOSPITALIZATION HEMODINAMICALLY STABLE -30 PRESYMPTOMATIC CONGESTION DECOMPENSATION Time Time preceding Preceding Hospitalization hospitalization (Days) (days) Adamson PB et al. Curr Heart Fail Rep

11 Monitoring through CardioMEMS

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13 CHAMPION TRIAL NYHA III pts with hospitalization Regardless of LVEF Device implanted in all (270 treat, 280 contr) 6 months randomized, then open access CHAMPION trial. JACC HF 2016

14 CHAMPION trial. Lancet 2011

15 HOSPITALIZATIONS Maggioni AP et al. ARNO registry. EUR J HEART FAILURE 2016

16 COPD

17 COPD DIAGNOSIS GOLD COPD Guidelines 2017

18 Canepa M et al. EUR J HEART FAILURE 2017

19 DIAGNOSTIC GAP - COPD in HF 1322/9409 (14.1%) ambulatory HF patients with clinical COPD Performed PFT? At least one COPD med? NO; 69,4% YES; 30,6% NO; 46% YES; 54% Canepa M et al. EUR J HEART FAILURE 2017

20 THERAPEUTIC GAP - COPD in HF Canepa M et al. EUR J HEART FAILURE 2017

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22 DIAGNOSTIC & THERAPEUTIC GAP About 30% of chronic HF patients have unrecognized airflow obstruction About 30% of chronic HF are mislabelled with COPD but have no airflow obstruction They do not receive bronchodilator therapy for symptoms improvements They do not receive proper HF medications but unnecesary bronchodilators Hawkins NM. Editorial EUR J HEART FAILURE 2017

23 HOSPITALIZATIONS Maggioni AP et al. ARNO registry. EUR J HEART FAILURE 2016

24 ATRIAL FIBRILLATION

25 Type of AF at Randomization Compared With Patients Without AF: HRs of Outcomes Mogensen et al. PARADIGM-HF & ATMOSPHERE. JACC 2017

26 Inflammation Prothrombotic state LV function LA volume Blood flow abnormalities thromboembolic risk (AF independent) HFrEF Paroxysmal / new-onset clinical AF ate diag osis ate preve tio Stroke Hospitaliz Canepa M, Ameri P et al. JACC 2018, accepted Letter to Mogensen et al. JACC 2017

27 CIED Inflammation ¼ of patients has a CIED Paroxysmal / new-onset subclinical AF ear y diag osis ear y preve tio Prothrombotic state LV function LA volume Blood flow abnormalities thromboembolic risk (AF independent) HFrEF Paroxysmal / new-onset clinical AF ate diag osis ate preve tio Stroke Hospitaliz Canepa M, Ameri P et al. JACC 2018, accepted Letter to Mogensen et al. JACC 2017

28 Different algorithms for different devices and brands Different programming Intracardiac electrograms revision needed (false positive) Device interrogation clinical visit No standardized interrogation report INTERNATIONAL JOURNAL of CARDIOLOGY 2017

29 Inflammation ¼ of patients has a CIED Prothrombotic state LV function LA volume Blood flow abnormalities thromboembolic risk (AF independent) HFrEF Paroxysmal / new-onset clinical AF ate diag osis ate preve tio Stroke Hospitaliz Canepa M, Ameri P et al. JACC 2018, accepted Letter to Mogensen et al. JACC 2017

30 AliveCor Kardia & REHEARSE-AF Study, Circulation 2017

31 LOOP study, ongoing. American Heart Journal 2017

32 TOMORROW S SOLUTIONS TODAY DIAGNOSTIC x3 THERAPEUTIC x1 PROGNOSTIC

33 ARNI to replace ACEi

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35 ARNI: Angiotensin Receptor Neprilysin Inhibitors ARNI SACUBITRIL SACUBITRILAT VALSARTAN Sing JSS et al. HEART 2017

36 Kaplan-Meier Estimates of Cumulative Rates (%) PARADIGM-HF: primary endpoint Cardiovascular Death or HF hospitalization NNT=21 Days After Randomization PARADIGM-HF. NEJM 2014

37 PARADIGM-HF: primary endpoint PARADIGM-HF. NEJM 2014

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39 % of patients eligible for ARNI 1396 ambulatory CHF patients in UK 1. LVEF 40% at baseline 2. LVEF 40% at fup 3. Alive at fup 4. Available at fup 5. On target dose ACEi/ARB 6. No controindications 7. Symptoms 8. NTproBNP> NTproBNP>600 Pellicori P, Clark AL et al. EJHF 2017

40 Only 28% of the 5000 HFrEF patients in the ESC HF Long-Term Registry are at ACEi/ARB target dose - still up-titration - side effects (symptomatic hypotension and/or worsening renal function) - no obvious reason Maggioni et al. EJHF 2013 No loss of the advantage of sacubitril valsartan over enalapril for morbidity and mortality in >40% of patients in PARADIGM-HF who had doses reduction of trial medication during follow-up. Vardeny et al. EJHF 2016 Rather than going to the trouble of titrating patients to full dose ACEi/ARB and then switching to an ARNI, it may be appropriate to initiate patients on the latter from the outset. Pellicori P, Clark AL et al. EJHF 2017

41 AHA/ACC HF Guidelines. Focused Update 2017

42 Selecting the right patients for ARNI YES HFrEF patients with LVEF 35% NYHA II-III & increased BNP/NT-proBNP SBP>100 mmhg Tolerating target ACEi/ARB MAYBE On low-dose ACEi/ARB ACEi/ARB naïve NO DATA NYHA IV/stage D HF Hospitalized HF HFpEF NYHA I/asymptomatic LVH Yancy CW, AHA Scientific Session 2017

43 ARNI Upcoming clinical studies A Randomized, Double-blind Controlled Study Comparing LCZ696 to Medical Therapy for Comorbidities in HFpEF Patients (PARALLAX) Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction (PARAGON-HF) comparison Of Sacubitril/valsartaN Versus Enalapril on Effect on ntpro-bnp in Patients Stabilized From an Acute Heart Failure Episode (PIONEER-HF) Prospective ARNI vs ACE Inhibitor Trial to DetermIne Superiority in Reducing Heart Failure Events After MI (PARADISE-MI) ARNI in Asymptomatic Patients With Elevated Natriuretic Peptide and Elevated Left Atrial Volume Index elevation (PARABLE) Comparison of Pre- and Post-discharge Initiation of LCZ696 Therapy in HFrEF Patients After an Acute Decompensation Event (TRANSITION)

44 TOMORROW S SOLUTIONS TODAY DIAGNOSTIC x3 THERAPEUTIC x1 PROGNOSTIC

45 RISK SCORES

46 TOMORROW HOSPITALIZATIONS DEATH

47 PREDICTING REHOSPITALIZATIONS Desai and Stevenson, CIRCULATION 2012

48 PREDICTING MORTALITY

49 PREDICTING MORTALITY Levy et al. SHFM. CIRCULATION 2006 Barlera et al. GISSI-HF. CIRCULATION HF 2013 Pocock et al. MAGGIC. Eur Heart Journal 2013

50 PREDICTING MORTALITY - overall RISK SCORES USED BY LESS THAN 4% OF CARDIOLOGISTS IN THE EORP HF LT REGISTRY Canepa M et al. Submitted first revision JACC HF

51 PREDICTING MORTALITY - individually 9282 chronic HF with 1-year fup DEAD = / 1661 ALIVE =7621 Allen LA et al. JAMA Cardiology 2017

52 Mozaffarian et al. CIRCULATION 2007

53 CUMULATIVE CONTEMPORARY INCIDENCE OF SD*: 1% by 3 months 2% by 6 months 3.3% by 1 year 8.8% by 3 years *pts with BB, ACEi/ARB & MRA Shen et al. NEJM 2017

54 MORTALITY/YEAR *CIRC HF 2013, In-HF OUTCOME 10% TOTAL MORTALITY 5.9%* 5% SUDDEN DEATH CV and NON-CV DEATH TODAY

55 PREDICTING MORTALITY

56 TOMORROW S SOLUTIONS TODAY DIAGNOSTIC - Pulmonary pressure monitoring - COPD diagnosis and treatment - Subclinical AF detection THERAPEUTIC - ARNI to replace ACEiARB PROGNOSTIC - Increasing relevance of prognostic risk scores

57 Molto ragionamento e poca osservazione conducono all'errore. Molta osservazione e poco ragionamento conducono alla verità. Alexis Carrel