La terapia non farmacologica

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1 Prevenire lo scompenso e le sue recidive Sessione II - Prevenzione, Terapia, Riabilitazione dello Scompenso Cardiaco La terapia non farmacologica

2 Prevenire lo scompenso e le sue recidive Terapia non farmacologica; Classificazione: 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

3 Terapia non farmacologica; Prevenire lo scompenso e le sue recidive Terapia Elettrica

4 Prevenire lo scompenso e le sue recidive Morte improvvisa nello scompenso cardiaco 8% 30% 95% 5% 62% Scompenso cardiaco Uretsky BF JACC 1997; 30: Scompenso cardiaco severo Stevenson WG Circulation 1993; 88: % 5% 25% 20% bradi VT/VF VTmono altre Cardiomiopatia ischemica Meissner MD Circulation 1991; 84:

5 Prevenire lo scompenso e le sue recidive Sudden death accounts for ~ 50% of mortality in advanced HF

6 % 1 year mortality Prevenire lo scompenso e le sue recidive Morte improvvisa nei trials sullo scompenso cardiaco NYHA I II III IV 40 morte improvvisa mortalità totale SOLVD-Pre DIG 1996 V-HeFT II CARVEDILOL VESNARINONE SOLVD-Treat ELITE 1997 UCLA CONSENSUS Stevenson WG. J Cardiovasc. Electrophysiol. 2001; 21:112-4

7 Prevenire lo scompenso e le sue recidive 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:

8 mortalità Prevenire lo scompenso e le sue recidive Mortalità e disfunzione VS nel post-infarto morte improvvisa mortalità totale anno 5 anni Tavazzi L Circulation 1997; 95:

9 Prevenire lo scompenso e le sue recidive Morte improvvisa nella miocardiopatia dilatativa mortalità totale morte imp. morte scompenso o trap. morte imp. 3 mesi n. event/100 pz/a mesi 3 m e s i Di Lenarda A Circulation 1998; 98: (suppl I): I-507

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11 Prevenire lo scompenso e le sue recidive 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 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%

12 Prevenire lo scompenso e le sue recidive Prevenzione secondaria: con ICD - metanalisi Effectiveness of ICDs in Preventing SD A Meta Analysis Secondary Prevention Absolute Reduction = 7% Number Need to Treat = 15 Lee DS: J Am Coll Cardiol 2003; 41: 1573

13 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:

14 Patients With Reduced Left Ventricular Ejection Fraction I Secondary Prevention: Implantable Cardioverter-Defibrillator IIa IIb III 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 Jessup M. JACC 53, n. 15, 2009:

15 ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities Epstein A. JACC 51, 21, 2008:

16 Implantable Cardioverter-Defibrillators secondary prevention I IIa IIb III 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. I IIa IIb III I IIa IIb III 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. ACC/AHA/HRS 2008 Epstein A. JACC 51, 21, 2008:

17 Prevenire lo scompenso e le sue recidive Incidenza morte improvvisa e totale eventi Incidenza totale in popolazione adulta Percentuale/anno Eventi/anno x 1000 Sottogruppo ad alto rischio coronarico Qualsiasi evento coronarico primario Scompenso E.F. < 30% Sopravvissuti ad arresto cardiaco extra-ospedaliero Pregresso I.M. TV/FV MADIT -MUSTT SCD-HeFT COMPANION MADIT 2 MADIT-CRT AVID-CIDS-CASH Myerburg RJ J Cardiovasc Electrophysiol 2001; 12:

18 JM Prevenire lo scompenso e le sue recidive HF in Primary Prevention Morbidity/Mortality Trials NYHA IDIOPATHIC NYHA POST-MI IV IV III III II II I I <30% <35% FE <30% <35% FE MADIT II (ICD) COMPANION (PM / ICD BiV) DEFINITE (ICD) SCD-HeFT (ICD)

19 Prevenire lo scompenso e le sue recidive Prevenzione primaria: metanalisi Absolute Reduction = 8% Number Need to Treat = 12 Nanthakumar K. J Am Coll Cardiol 2004; 44:

20 Patients With Reduced Left Ventricular Ejection Fraction Primary Prevention: Implantable Cardioverter-Defibrillator I IIa IIb III 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 postmyocardial 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. Jessup M. JACC 53, 15, 2009: Modified

21 Implantable Cardioverter-Defibrillators primary prevention post-mi I IIa IIb III 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. I IIa IIb 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. I IIa IIb III 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. ACC/AHA/HRS 2008 Epstein A. JACC 51, 21, 2008:

22 Implantable Cardioverter-Defibrillators primary prevention non ischemic DCM I IIa IIb III ICD indicated in patients with nonischemic DCM who have an LVEF 35% and who are in NYHA II or III. I IIa IIb III ICD is reasonable for patients with unexplained syncope, significant LV dysfunction, and nonischemic DCM. 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. ACC/AHA/HRS 2008 Epstein A. JACC 51, 21, 2008:

23 Implantable Cardioverter-Defibrillators I IIa IIb III ICD is reasonable for nonhospitalized patients awaiting transplantation. I IIa IIb III ICD is reasonable for patients with cardiac sarcoidosis, giant cell myocarditis, or Chagas disease. 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. ACC/AHA/HRS 2008 Epstein A. JACC 51, 21, 2008:

24 Mortality Reduction (%) Prevenire lo scompenso e le sue recidive Secondary Prevention Mortality reductions with ICDs Primary Prevention 60% 54% 60% 50% 40% 30% 20% 31% 37% 20% 31% 41% 23% 36% 10% 0% AVID 3 Years CASH 2 years CIDS 3 years MADIT 2 years MUSTT 5 years MADIT II SCD-HeFT 3 years DEFINITE 5 years COMPANION 3 years 1 years ICD mortality reductions in primary prevention trials are equal to or greater than those in secondary prevention trials.

25 Strategy for use of drugs and devices in symptomatic HF and systolic dysfunction Dickstein K European Heart Journal 2008, 29: Sintomi di Scompenso Cardiaco + Ridotta Frazione d Eiezione Diuretico + ACE-I + ß-bloccante titolati alla stabilità clinica si Persistenza di segni e sintomi? no Aggiungere antagonista dell aldosterone o ARB si Persistenza di segni e sintomi? no QRS>120 ms? LVEF<35%? si no si no Considerare: CRT-P or CRT-D Considerare: Digossina, idralazina/nitrati, LVAD, trapianto Considerare: ICD Nessun ulteriore trattamento

26 Prevenire lo scompenso e le sue recidive Conclusioni 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

27 Prevenire lo scompenso e le sue recidive La terapia di resincronizzazione cardiaca

28 Elements of Cardiac Dyssynchrony Atrioventricular Intraventricular Interventricular riduce il tempo di riempimento diastolico prolunga il tempo di contrazione prolunga il rigurgito mitralico contrazione sistolica settale precoce Cazeau, et al. PACE 2003; 26[Pt. II]: dissinergia movimento parietale

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30 Issues associated with heart failure Mechanism II ventricular resynchronization Sinus node AV node Intraventricular Activation Organized ventricular activation sequence Coordinated septal and free-wall contraction Improved pumping efficiency Conduction block Stimulation therapy

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34 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:

35 Patients With Reduced Left Ventricular Ejection Fraction I IIa IIb III Resynchronization Therapy 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. Jessup M. JACC 53, 15, 2009:

36 Treatment strategy for the use of drugs and devices in patients with symptomatic HF and systolic dysfunction Sintomi di Scompenso Cardiaco + Ridotta Frazione d Eiezione Diuretico + ACE-I + ß-bloccante titolati alla stabilità clinica si Persistenza di segni e sintomi? no Aggiungere antagonista dell aldosterone o ARB si Persistenza di segni e sintomi? no QRS>120 ms? LVEF<35%? si no si no Considerare: CRT-P or CRT-D Considerare: Digossina, idralazina/nitrati, LVAD, trapianto Considerare: ICD Nessun ulteriore trattamento Dickstein K European Heart Journal 2008, 29:

37 ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities May 2008

38 Cardiac Resynchronization Therapy* in Patients With Severe Systolic Heart Failure I IIaIIbIII 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.

39 Cardiac Resynchronization Therapy* in Patients With Severe Systolic Heart Failure I IIa IIb III I IIa IIb III 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. I IIa IIb III 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. 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. Jessup M. JACC 53, 15, 2009:

40 Cardiac Resynchronization Therapy* in Patients With Severe Systolic Heart Failure I IIa IIb III I IIa IIb III 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.

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43 Prevenire lo scompenso e le sue recidive Conclusioni 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.

44 Ultrafiltrazione 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 venovenoso o artero-arterioso dove una membrana semiperrmeabile filtrante lascia passare l acqua e i soluti con un peso molecolare inferiore ai 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

45 Terapia invasiva percutanea Prevenire lo scompenso e le sue recidive 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)

46 Terapia chirurgica Prevenire lo scompenso e le sue recidive Chirurgia coronarica Chirurgia valvolare Aneurismectomia ventricolare sinistra Trapianto cardiaco