Appropriatezza clinica nella diagnosi e terapia della Cardiopatia Ischemica Cronica

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1 Tigullio Cardiologia Santa Margherita Ligure, 7/8 aprile 2016 Cardiopatia Ischemica Appropriatezza clinica nella diagnosi e terapia della Cardiopatia Ischemica Cronica G. Casolo UOC Cardiologia Ospedale della Versilia Consiglio Direttivo Nazionale ANMCO

2 Appropriatezza Concetto molto utilizzato, di difficile declinazione, soggettivo, non universale, non costante nel tempo, applicato a dimensioni differenti, in genere a fini di contenimento di spesa Diagnostica Prescrittiva Terapeutica Economica Professionale Organizzativa La miglior scelta per lo stato di salute del nostro paziente compatibilmente con le risorse disponibili e con un progetto di cura che abbia un reale valore

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4 Outline Cosa intendiamo per cardiopatia ischemica cronica? Il paziente come raggiunge questa diagnosi? Quali strumenti diagnostico-terapeutici devono essere impiegati nel singolo paziente? Cosa deve o dovrebbe guidare la scelta e il tipo di trattamento?

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6 Diagnosi e terapia della Cardiopatia Ischemica Cronica <="">

7 Clinical Conditions associated with the definition of Chronic CAD Chronic stable angina Post-myocardial infarction Post-revascularization CAD Obstructive CAD CAD with demonstration of ischemia CAD with demonstration of viability Left ventricular dysfunction and CAD

8 Clinical Patterns of Stable Coronary Artery Disease REGISTRO CLARIFY Prospective Observational Longitudinal Registry of Patients With Stable Coronary Artery Disease outpatients (63.2%) had undergone a noninvasive test Steg et Al. JAMA Intern Med. 2014

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13 Observed prevalence of angiographically confirmed 50% stenotic CAD Cheng et Al. Circulation. 2011

14 Observed prevalence of angiographically confirmed 50% stenotic CAD Cheng et Al. Circulation. 2011

15 Linee Guida ESC Quanto è appropriato non fare diagnosi di malattia ma solo di prognosi? La prognosi è una malattia? Siamo sicuri di conoscere quali sono i determinanti prognostici al punto di evitare di conoscere l anatomia coronarica oggi?

16 Outcome of Stable Coronary Artery Disease (Registro Clarify) Steg et Al. JAMA Intern Med

17 Primary Outcome and Various Composite Outcomes for Patient Groups Steg et Al. JAMA Intern Med. 2014

18 Annual Event Rates Stratified by Cardiac Computed Tomography Angiography Result Hulten et al. JACC, 2011

19 Appropriatezza diagnostica e terapeutica nel paziente con CAD cronica Diagnostica Non invasiva (stress eco, SPECT,MDCT) Invasiva (ICA - FFR - IVUS) Terapeutica Terapia medica Terapia interventistica e chirurgica

20 Lin GA et Al. BMJ 2008

21 Rate ratio of stress testing prior to PCI in USA 44% in media di stress test prima di PCI Lin GA et Al. BMJ 2008

22 Proporzione di test non invasivi svolti in 2700 Ospedali Premier database includes administrative, operational, and some clinical data from 2700 hospitals in the United States patients at 224 hospitals Admissions for suspected ischemia Safavi et Al. JAMA Int Med 2014

23 Rapporto tra test di ischemia e coronarografie e rivascolarizzazioni Safavi et Al. JAMA Int Med patients at 224 hospitals Admissions for suspected ischemia

24 Relazione tra test di ischemia e angiografia, rivascolarizzazioni e reingressi Safavi et Al. JAMA Int Med 2014

25 L inappropriatezza genera inappropriatezza

26 National Cardiovascular Data Registry 398,978 patients x 663 Hospitals Patel et al. N Engl J Med 2010;362: % had obstructive coronary artery disease Patients without known coronary artery disease who were undergoing elective catheterization

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28 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease

29 Variation in Hospital rate of asymptomatic patients at angiography Bradley et Al. JAMA Int Med 2014

30 Relazione tra ICA eseguita in pazienti asintomatici e PCI inappropriate Bradley et Al. JAMA Int Med 2014

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33 Data from patients who underwent CABG surgery and PCI without acute coronary syndrome or previous CABG surgery in New York in 2009 and 2010

34 Rating Cases as Appropriate for Revascularization According to ACC/AHA Appropriate Use Criteria Patients Hannah et Al. JACC 2012

35 JAMA Int Med 2014

36 Rita F. Redberg Sham Controls in Medical Device Trials PCI, a widely used procedure for treating stable coronary artery disease, has never been investigated in a blinded trial. Some nonblinded RCTs have shown that PCI has a beneficial effect on anginal symptoms, but there appears to be no difference between PCI and medical therapy in rates of the objective end points of nonfatal myocardial infarction and death due to cardiac causes. It is possible, therefore, that the perceived symptomatic benefit is actually a placebo effect and not attributable to PCI. Although a blinded trial would be relatively straightforward if two groups of patients were randomly assigned to a cardiac catheterization procedure, as was done for renal-artery denervation, such a study has yet to be performed, and the important question of PCI's actual clinical benefit therefore remains unanswered N ENGL J MED September 4, 2014

37 Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis E-ZES=zotarolimus eluting (Endeavor) stent; R-ZES=zotarolimus eluting (Resolute) stent; EES=everolimus eluting stent Windeker et Al. BMJ 2014

38 Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis E-ZES=zotarolimus eluting (Endeavor) stent; R-ZES=zotarolimus eluting (Resolute) stent; EES=everolimus eluting stent Windeker et Al. BMJ 2014

39 Metanalisi effetto PCI in pazienti con CAD stabile e ischemia Stergiopoulos et l. JAMA Intern Med 2014

40 Metanalisi effetto PCI in pazienti con CAD stabile e ischemia Morte IMA non fatale Revasc Unplanned Angina in FU Stergiopoulos et l. JAMA Intern Med 2014

41 Freedom From Death, MI, or NSTE-ACS by Percent of Ischemic Myocardium or by Anatomic Burden Mancini et Al. Jacc Interv 2014

42 Proportion of Patients With Death, Myocardial Infarction or Non ST- Segment Elevation Acute Coronary Syndrome by Ischemic Myocardium and Atherosclerotic Burden of Disease Mancini et Al. Jacc Interv 2014

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45 Hiroo Onoda remained on an island in the Philippines until 1974 (29 years)

46 Declines in Rates of Death from Major Noncommunicable Diseases in the United States, 1950 to 2010 Hunter et Al. NEJMed 2013

47 Cardiovascular disease mortality trends for males and females (United States: ). Mozaffarian et al. Heart and Stroke Statistics Circulation 2016

48 US age-standardized death rates attributable to CV disesases, 2000 to % Mozaffarian et al. Heart and Stroke Statistics Circulation 2016

49 Cardiovascular disease in Europe epidemiological update 2015 European Heart Journal Advance Access published August 25, 2015

50 Prevalence of CAD (2010)

51 Prevalence of coronary heart disease by age and sex Mozaffarian D et al. Circulation. 2015;131:e29-e322

52 Prevalence of angina pectoris by age and sex (National Health and Nutrition Examination Survey: ) Mozaffarian et al. Heart and Stroke Statistics Circulation 2016

53 Incidence of angina pectoris (deemed uncomplicated on the basis of physician interview of patient) by age and sex (Framingham Heart Study ) Mozaffarian et al. Heart and Stroke Statistics Circulation 2016

54 Secular trends in age-and sex-standardized prevalence rates of angina for adults aged 40 years in the United States Mozaffarian et al. Heart and Stroke Statistics Circulation 2016

55 Temporal Trends in the Frequency of Inducible Myocardial Ischemia During Cardiac Stress Testing Rozansky et Al. JACC 2013

56 Accuracy of a Test of Ischemia

57 All aumentare della prevalenza si riducono i falsi positivi e i falsi negativi

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61 30 day and day mortality after first time hospitalisation for myocardial infarction between 1984 and 2008, according to comorbidity category Schmidt M et Al. BMJ 2012

62 Years after PCI 64% 36% Spoon et Al, Circulation 2014

63 Variation in patients perceptions of elective percutaneous coronary intervention in stable coronary artery disease 10 US academic and community hospitals performing percutaneous coronary interventions between 2009 and patients with stable coronary artery disease undergoing elective percutaneous coronary intervention. Kureshi et Al. BMJ 2014

64 Variation in patients perceptions of elective percutaneous coronary intervention in stable coronary artery disease Kureshi et Al. BMJ 2014

65 Reasons for performing and beliefs about PCI Rothberg et Al. Ann Intern Med. 2010

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73 Appropriatezza Clinica Evidenze scientifiche datate Popolazioni differenti e più anziane Prognosi di popolazione in miglioramento Ruolo dell Ischemia moderato-severa in discussione Terapie (anche farmacologiche) sempre più efficaci (non sempre prive di effetti indesiderati) Peso delle comorbidità crescente

74 Conclusioni L appropriatezza è un argomento complesso e difficile da declinare in modo univoco o condiviso Le basi su cui poggiano le nostre idee di appropriatezza sono deboli e spesso non appropriate per il nostro singolo paziente L appropriatezza clinica non può sottrarsi da una impostazione Professionale ispirata ai più elevati ideali etici, dalla esperienza, dal buon senso e da un confronto col paziente Dal costo, l appropriatezza Clinica giunge alla dimensione del Valore dell Atto Clinico. Tale valore non ha prezzo