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La gestione della Dimissione Ospedaliera e della Prevenzione
Secondaria
HospitalED
• Admit? • CCU?
•Transfer?
CCU
• Acute Cath?
•Tx to Floor?
InLab
• Revasc?
• Other Rx?
Pre- Discharge
• Right meds
•Right ptEducation
3-Mo Eval
• Re-assess EF •Lipids at goal?•On right meds?•On right dose?• Depression?• Other risks addressed?
Transitional ACS Care: Not missing the steps
International Variation in and FactorsAssociated With Readmission After MI
Kociol RD, et al. JAMA. 2012;307:66
Assessment of Pexelizumab in ACS study
Adjusted Odds Ratio of 30-Day Post-Discharge Readmission
Kociol RD, et al. JAMA. 2012;307:66
30 day and 31–365 day mortality after first time hospitalisation for myocardial infarction between 1984 and 2008
in a Danish nationwide cohort study
Schmidt et al. BMJ 2012
SCA: Punta dell’Iceberg dell’Aterotrombosi
SCA = sindrome coronarica acuta; UA = unstable angina; NSTEMI = nonST-segment elevation myocardial infarction; STEMI = ST-segment elevation myocardial infarction.
Adapted from Bhatt DL. J Invasive Cardiol. 2003;15(suppl B):3B-9B.
Subclinico
Persistenza ipereattività Piastrinica
Presenza diPlaccheCoronariche multiple
Infiammazionevascolare
Clinico
Rottura Acuta placca evento: (UA/NSTEMI/STEMI)
Prevenzione secondariaScopo del Trattamento
Migliorare la sopravvivenza
Prevenire il Reinfarto
Prevenire il rimodellamento
del VSx
Prevenire lo scompenso
cardiaco
Ridurre il rischio di aritmie
Statistiche US: Eventi post-SCA
Eventi a 5 aaMorte
(%)IM ricorrente o CHD fatale (%)
Scompenso (%)
40-69 aa M 15 16 7
F 22 22 12
> 70 aa M 50 24 21
F 56 24 25
O’Connor R et al.Circulation 2010
Torabi, A. et al. J Am Coll Cardiol 2010;55:79-81
Proportion of Patients Who Died With or Without Preceding Evidence of HF Subsequent to Discharge From Index
Admission
7773 pts 896 pts
Steg GRACE Registry Circulation 2004Di Chiara BLITZ Study Eur Hear J 2003
Killip >1 = 22% Scompenso cardiaco = 20%
Nicolosi GISSI-3 trial Eur Heart J 1996
Frazione di eiezione < 40% = 16% Frazione di eiezione < 45% = 25%
IN-ACS Outcome on file
Incidenza di scompenso e disfunzione ventricolare sinistra postinfartuale
Dati SDO 200490.175 pazienti dimessi dopo infarto miocardico acuto
20.000 con indicazione a riabilitazione cardiologica degenziale
G Ital Cardiol 2011;12 (3):219-229
Documento di consenso ANMCO-IACPR/GICRCriteri di accesso alla riabilitazione cardiologica degenziale
Premesse fondamentali
G Ital Cardiol 2011;12 (3):219-229
- Modificazioni dell’epidemiologia clinica dell’ IMA- Concetto di “priorità”alla riabilitazione cardiologica- Priorità all’alto rischio clinico- Riformulazione dell’offerta delle strutture riabilitative
1. Scompenso cardiaco e/o FE<40%; IM > 1/3 1.------- Accesso a Cardiologia riabilitativa degenziale o, in
sua assenza, controlli precoci < 30 gg
2. Predittori di rimodellamento e scompenso (FE, riempimento diastolico restrittivo, WMSI, livello enzimi, età, IM =1)
3. Predittori di re-infarto miocardico (diabete mellito, caratteristiche malattia coronarica, insufficienza renale, risultato subottimale procedure, persistenza rischio cardiovascolare elevato)
4. Livello di fattori di rischio cardiovascolare 2-3-4 --------- Controllo clinico strumentale a 30 giorni
Gerarchia delle variabili prognostiche utili alla dimissione,percorso assistenziale e timing dei controlli
CEN ANMCO-GIC 2011
Criteri per la selezione dei pazienti da inviare nei Centri di Cardiologia Riabilitativa
Documento di Consenso ANMCO /GICR-IACPR
… Il Panel ritiene quindi prioritario l’invio a strutture riabilitative degenziali, dopo la fase acuta, dei pazienti IMA ad alto rischio clinico:
• IMA con scompenso o con disfunzione ventricolare sinistra (frazione di eiezione inferiore al 40%).
• IMA con ricoveri prolungati in fase acuta o con complicanze o con comorbidità
• IMA in persone che svolgono vita estremamente sedentaria o anziani
• Il Panel ritiene prioritario un ciclo riabilitativo preferibilmente ambulatoriale per pazienti con alto rischio clinico-cardiovascolare:
• Rivascolarizzazione incompleta, coronaropatia diffusa o critica, multipli fattori di rischio, resistenza a mutare lo stile di vita, specie se in pazienti giovani
• Hospital discharge summary:– Confirms diagnosis– Provides results of investigations performed and future investigations
required– Documents any in-hospital complications and resulting interventions– Provides details of medication prescribed with guidance on up-titration– Includes the patient’s agreed care plan
• All patients should receive an individualised management plan, which:
– Is culturally sensitive
– Contains evidence-based information
– Includes input from the patient and carers/family
– Provides recommendations on daily living
– Documents what to expect of primary care services
Discharge Form
Discharge Protocols• Enhance communication with patient and
between specialist(s) and primary care physicians
• Shared targets for improvementShared targets for improvement• High-quality data feedbackHigh-quality data feedback
• Medications: aspirin, thienopyridine, ACE inhibitor, β-blocker, statin
• Diet, exercise, smoking cessation recommendations
• Patient symptom awareness, “Act in Time” protocol
• Wallet-/purse-sized copy of ECG
• Follow-up appointments
• Based on the guidance, the Follow Your Heart group developed complementary practical, user-friendly tools for primary care clinicians and patients
• Tools summarise the guidance for incorporation into day-to-day practice for clinicians and day-to-day life for patients and their families
Complemetary tools for HCPs and patients
1. Cardiac rehabilitation and ongoing care 2. Lifestyle modification3. Goal of intervention4. Therapeutic interventions 5. Integrated communication
Five steps to optimal post-ACS care
1. Cardiac rehabilitation and ongoing care
• Cardiac rehabilitation: – Vital to help post-MI patients improve risk factors for cardiovascular
disease (CVD)– Provides link in post-MI care between primary and secondary care
• Each post-MI patient should have an individualised plan developed prior to hospital discharge
• Each cardiac rehabilitation plan should: – Enable patients to understand and take responsibility for their recovery
and continued health
– Introduce concept of risk and importance of cardiovascular (CV) risk factors
– Address specific areas concerning patients and their partners
2. Lifestyle modification
• Lifestyle changes are essential to improve CV health
• Partners and family members should be encouraged to adopt positive healthy lifestyle changes together
Eat a healthy balanced diet4
• Consider a Mediterranean-style diet. Increase fresh food intake and reduce processed foods5
• Eat less fat. Reduce intake of foods high in saturated fat, e.g. fatty and processed meat, full-fat dairy products, biscuits, cakes, pastries and some convenience snack foods. Opt for unsaturated fats, e.g. sunflower and olive oil (polyunsaturated and monounsaturated fat)6
• Eat more fruit and vegetables – at least five portions of different types a day7
• Choose wholegrain and high-fibre foods, e.g. wholegrain rice/pasta, wholemeal bread, oats, seeds, nuts, pulses, etc8.
• Eat oily fish, at least two portions a week to provide omega-3 (e.g. salmon, trout, mackerel) 9. Consider 1 g Omacor per day as an alternative• Reduce salt intake, aim for <6 g a day10. Beware of hidden salt content• Consider foods enriched with plant sterols or stanols, e.g. yoghurt, milk,margarine spreads11
Increase physical activity12
• Be physically active, e.g. take the stairs, walk to shops, wash the car• Aim for at least 20–30 minutes of moderate activity each day to the pointof mild breathlessness, e.g. walking, jogging, cycling, dancing or swimming
Do not smoke13• Post-MI patients should not smoke• Smokers should be offered medication for smoking cessation andreferred to local stop-smoking services
Manage weight13
• Balance energy intake with energy expenditure • Advice should be provided to individuals when body mass index (BMI) >25 kg/m2 or those with an increased waist circumference • If overweight aim to lose around 0.5 kg/1 lb per week
Limit alcohol intake12
• Drink alcohol in moderation:, women ≤1–2 units/day, men ≤2–3 units/day
3. Goal of intervention
Blood pressure • <130/80 mmHg13
• <125/75 mmHg for patients with chronic kidney disease (CKD)14
• Goal of intervention is to achieve optimal control of all modifiable CV risk factors
• Clinical evidence consolidated for concise, definitive guidance on optimal targets
Blood sugar • HbA1c <6.5%13
Weight
BMI13
• <25 kg/m2
Waist circumference16
• Europidso Male <94 cmo Female <80 cm• South Asians and Chineseo Male <90 cmo Female <80 cm
Key: BMI = body mass index; HbA1c = glycosylated haemoglobin; HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; TC = total cholesterol
Perk J, et al. Eur Heart J doi:10.1093/eurheartj/ehs092
European Guidelines on Cardiovascular Disease Prevention (Version 2012)
4. Therapeutic interventions
Riduzione del rischio
• Aspirina – tienopiridine* 20-30%
• Beta-bloccanti* 20-35%
• ACE-inibitori* 22-25%
• Statine* 25-42%
*I quattro farmaci con i quali devono essere trattati tutti i pazienti con aterosclerosi, salvo controindicazioni esistenti e documentate
Adherence Rates After Discharge for ACS if Therapy is Started In-Hospital
GRACE Registry: 21,408 patients, multinational, assessment at discharge and 6 monthsEagle KA, et al. Am J Med. 2004;117:73-81.
92 8880
87
ASA -blocker ACEI Statin0
20
40
60
80
100
Per
cent
of P
atie
nts
[11,465/12,463] [1906/2379][6796/7738] [5522/6320]
Discharge Medication Use
*LVEF <40%, CHF, DM, HTN.†Known hyperlipidemia, TC, LDL.
Q4 2003 CRUSADE data. © 2003 Duke Clinical Research Institute. Used with permission. Available at: http://www.crusadeqi.com.
93% 89%
0%
20%
40%
60%
80%
100%
Aspirin β-Blockers ACEInhibitors*
67%
Lipid-LoweringAgent†
84%
67%
Clopidogrel
Interruzione dei trattamenti raccomandati durante il follow-up in pazienti con Pregresso IMA
Dati del registro SIMG - Health Search - JCVM 2009
Adherence to statins after two years, by condition
Jackevicius CA, et al. JAMA 2002;288:462
Why adherence matters
Results of failure to adhere to prescribed medications: Increased hospitalization Poor health outcomes Increased costs Decreased quality of life Patient death
Benner JS, et al. JAMA 2002;288:455
“Of all medication-related hospital admissions in the United States, 33 to 69 percent are due to poor medication adherence, with a resultant cost of approximately $100 billion a year.”
Perk J, et al. Eur Heart J doi:10.1093/eurheartj/ehs092
European Guidelines on Cardiovascular Disease Prevention (Version 2012)
OSSERVATORIO ARNO SUI FARMACI CARDIOVASCOLARI
L’Osservatorio ARNO è composto da una rete di 32 ASL sparse sul territorio nazionale e raccoglie i dati di circa 10,5 milioni di abitanti.
Data Dimissione
01/01/2007
Periodo di
Accrual
01/01/2008
31/12/2008
31/12/2009
Pregresso(-365 gg rispetto alla data di dimissione per
SCA)
Follow-up(+365 gg rispetto alla data di
dimissione per SCA)
Pazienti con Sindrome Coronarica Acuta (nel periodo di accrual): 7.082
Terapia I semestre Totale %Aspirina 1.765 33,4% Aspirina + Clopidogrel 2.740 51,9%Aspirina + Ticlopidina 246 4,7%Altra terapia antiaggregante* 456 8,6%Nessuna terapia nel I semestre
75 1,4%
Totale 5.282 100,0%
OSSERVATORIO ARNO SUI FARMACI CARDIOVASCOLARI
N. pazienti: 5.207
Evento indice
Doppia antiaggregazioneAspirinaAspirina +
ClopidogrelAspirina + Ticlopidina
solo SCA (N=4.250)
1.099 (25,9%)
124 (2,9%)1.529
(36,0%)SCA +
Rivascolarizzazioni
(N=2.342)
1.641 (70,1%)
122 (5,2%)236
(10,1%)
Trattati con antiaggreganti nel follow-up: 5.117
N. trattati aderenti nel I semestre: 3.481 (68,0%)
N. trattati aderenti nel I e nel II semestre: 3.084
(60,3%)
70,8
47,6
55,4
36,2
0 20 40 60 80
Aspirina + Clopidogrel
Aspirina + Ticlopidina
%
Aderenti nell'anno Aderenti nel primo semestre
OSSERVATORIO ARNO SUI FARMACI CARDIOVASCOLARI
Biondi-Zoccai G, et al. Eur Heart J 2006 27:2667
Aspirin Discontinuation in 50,279 CAD Patients
Increased Thrombotic Risks
OR=89.8(29.9-270)
HR=19.2(5.6-65.5)
OR=4.8(2.0-11.1)
HR=13.7(4.0-46.7)
Od
ds/
Haz
ard
Rat
io
Iakovou et al.JAMA 2005
Park et al.Am J Card 2006
Kuchulakanti et al.Circulation 2006
Airoldi et al.Circulation 2007
Premature Discontinuation of Antiplatelet Txas Predictor of Stent Thrombosis
Wenaweser P et al, J Am Coll Cardiol 2008;52:1134
Status of Antiplatelet Treatment and Time of Definite DES Thrombosis
Early Stent Thrombosis
Late Stent Thrombosis
Very Late Stent Thrombosis
0%
25%
50%
75%
100%
87
9
416
42
42
68
20
12
No Antiplatelet Therapy
Single Antiplatelet Therapy
Dual Antiplatelet Therapy
4-Year results from a large 2-Institutional (Rotterdam/Bern) cohort study
8146 patients (SES/PES implantation in 2002-2005)
Predictors of Low Clopidogrel Adherence Following PCI
Adherence to daily medications before PCIassessed in 284 pts using the
8-item Morisky Medication Adherence Scale (MMAS-8) and categorized as low (score <6), medium (score 6 to <8), or high (score 8).
Muntner P, et al. Am J Cardiol 2011;108:822
Rossini R et al. Am J Card 2011, 107: 186
Discontinuation Causes:
Surgery 34.5% Bleeding 21% Medical decision 17.6% Dental interventions 7.6% Economic/burocratic reasons 5.9% Anticoagulant therapy 5.0%
8.8% of patients discontinued one or both antiplatelet agents within the first 12 months (early discontinuation) and 4.8% withdrew aspirin after 1 year (late discontinuation)
DiscontinuationCauses
5. Integrated communication
• Good communication between secondary and primary care, community services and the patient is essential12
• Post-ACS hospital discharge summary is vital component of successful communication24
GUIDELINES
Smooth Transition From Acute Care to Long-Term Management
Primary Care
Secondary Prevention
Cardiology
Acute Care
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