Richard Horton , Lancet 2005
Malattia Cronica : tempo…..
“A disease that persists for a long time.
A chronic disease is one lasting 3 months or more, by the definition of the U.S.
National Center for Health Statistics.
“A disease lasting indefinitely. “
“An illness marked by long duration or frequent recurrence”
Malattia Cronica : prognosi….
“Chronic diseases generally cannot be prevented by vaccines or cured by
medication, nor do they just disappear
“A disease that can be controlled but not cured”
“A disease with one or more of the following characteristics: permanence,
leaves residual disability, caused by non-reversible pathological alternation,
requires special training of the patient for rehabilitation, or may require a
long period of supervision, observation, or care”
Cause delle malattie croniche
Determinanti
socioeconomici
culturali ,politici,
ambientali
Globalizzazione
Urbanizzazione
Invecchiamento
della popolazione
Fattori di rischio
comuni , modificabili
Dieta incongrua
Sedentarietà
Uso di tabacco
Fattori di rischio
non modificabili
Età
Ereditarietà
Fattori di rischio
intermedi
MALATTIA
CRONICA
Ipertensione
Ipotolleranza
glucidica
Obesità
Dislipidemia
Mal CV
Diabete
BPCO
Neoplasia
Preventing chronic diseases: a vital investment — WHO global report. Geneva:
World Health Organization, 2005.
Preventing chronic diseases: a vital investment — WHO global report. Geneva:
World Health Organization, 2005.
Did you know??
Chronic diseases
 Cardiovascular disease, mainly
heart disease, stroke
 Cancer
 Chronic respiratory diseases
 Diabetes
35 000 000
Strong et al, Lancet 2005
Millions of Cases of Diabetes in 2000 and Projections for 2030, with Projected Percent Changes.
Data are from Wild S et al. : Diabetes Care 2004;27:1047
Booth GL Lancet 2006; 368: 29–36
Relation between age and rates of AMI or
death from any cause in men and women
according to presence of diabetes and
previous AMI
Recent AMI: polynomial distribution. No recent
AMI: exponential istribution.R2 >0,97 for each
dotted line. Recent AMI=within 3 years of
baseline.
Diabetes confers an equivalent
risk to ageing 15 years
Prevalence of Diabetes*
100%
90%
80%
70%
60%
50%
P=0.004
40%
30%
20%
10%
0%
Czech
Rep.
Finland
France
Germany
Hungary
Italy
Netherlands
Slovenia
ALL
Survey 1
21.8%
15.4%
16.7%
13.5%
26.6%
17.2%
10.3%
17.4%
17.4%
Survey 2
21.5%
18.7%
27.5%
13.5%
21.1%
21.8%
13.2%
23.8%
20.1%
Survey 3
30.8%
19.1%
34.2%
22.6%
44.8%
21.7%
20.6%
18.8%
28.0%
* Self-reported history of diagnosed diabetes
S2 vs. S1 : P=0.21
S3 vs. S2 : P=0.02
S3 vs. S1 : P=0.001
Euro Heart Survey Programme 2007
ESC Quality Assurance Programme to Improve Cardiac Care in Europe
Risks are increasing
Prevalence of Obesity*
100%
90%
80%
70%
60%
P=0.0006
50%
40%
30%
20%
10%
0%
Czech
Rep.
Finland
Survey 1
31.4%
29.6%
33.4%
23.0%
23.3%
22.4%
18.9%
19.2%
25.0%
Survey 2
40.1%
33.6%
37.5%
30.6%
36.8%
23.6%
28.2%
28.0%
32.6%
Survey 3
37.9%
26.4%
36.8%
43.1%
49.3%
29.4%
26.5%
39.1%
38.0%
* Body mass index ≥ 30 kg/m²
France Germany Hungary
Italy
NetherSlovenia
lands
S2 vs. S1 : P=0.009
S3 vs. S2 : P=0.051
S3 vs. S1 : P=0.0002
Euro Heart Survey Programme 2007
ESC Quality Assurance Programme to Improve Cardiac Care in Europe
ALL
Estimated prevalence of GOLD stage 2 or
higher COPD
Mannino DM :Lancet 2007; 370: 765–73
The ARIC Study:Mannino DM:Respir Med 2006; 100: 115
Cosa e’una riacutizzazione di BPCO dal punto di vista clinico?
Funzione
Normali oscillazioni
stato clinico
Riacutizzazioni ?
CHEST 2000; 117:398S
tempo
Peggioramento acuto, inatteso, sostenuto…
Segni e
sintomi
Respiratori
 dispnea (respiro corto, rapido)
 tosse
 espettorato  purulento
Sistemici
 temperatura
 frequenza cardiaca
 stato mentale
prevalenza di ipertensione arteriosa nel mondo:
un’ epidemia incombente
1 miliardo di ipertesi
USA & Canada
Europa
28%, 50 milioni
38-55%,  266 - 385 milioni
Wolf-Maier K et al. Hypertension 2004
Cina
27%,  130 milioni
JNC 7 2003 Dongfeng G et al Hypertension 2002
Pressione e mortalità
ictus
Ischemia cardiaca
sistolica
diastolica
IV=(P≥65/P≤14)*100
242.0
(da Pulignano G, 2005)
Sempre più su……….
Number of Cardiovascular Deaths Projected
to 2020
25.000.000
20.000.000
2002
2020
15.000.000
Millions
10.000.000
5.000.000
0
Lower Income Higher Income
Si può fare qualcosa?
160 DIABETICI TIPO 2
FOLLOW UP 7.8 ANNI
ETA’ MEDIA 55 A.
TUTTI MICROALBUMINURICI
Terapia intensiva su tutti i
fattori di rischio
- 20%
Gaede P. NEJM 2003;348:383
Benefici della terapia antipertensiva
dimostrati nei trials con PA clinica
(riduzione di circa 10 sist./5 dia. mmHg)
–35-40%
-20-25%
Riduzione %
del rischio
relativo
-50%
rallentamento progressione IR
RR=0.64
BMJ published online 11 Oct 2007;
12 studi , 8307 pazienti
• 297 pts per 4.2 anni
• età media 75 anni
• 50% ischemici
• 30% diabetici
Home Based Intervention
+ 28%
Stewart S Circulation 2002;105:2861
Authors’ conclusions
Exercise training improves exercise capacity and quality of life in
patients mild to moderate heart failure in the short term. One study found
beneficial effects of exercise on cardiac mortality and hospital
readmissions over 3 years of follow-up, the remaining included studies
did not aim to measure clinical outcomes and were of short duration.
The findings of the review are based on small-scale trials in patients who
are unrepresentative of the total population of patients with heart failure.
Other groups (more severe patients, the elderly,women) may also benefit.
Large-scale pragmatic trials of exercise training of longer duration,
recruiting a wider spectrum of patients are needed to address these issues.
The Cochrane Library 2007, Isssue 4
BMJ 2006;332:1379
AUTHORS’CONCLUSIONS
“The results of this meta-analysis strongly support respiratory
rehabilitation including at least four weeks of exercise training as part of
the spectrum of management for patients with COPD.
We found clinically and statistically significant improvements in
important domains of quality of life, including dyspnea, fatigue
emotional function.
When compared with the treatment effect of other important modalities
of care…rehabilitation resulted in greater improvements in important
domains of health-related quality of life and functional exercise
capacity.”
Conclusion
Early pulmonary rehabilitation after admission to
hospital for acute exacerbations of COPD is safe and
leads to statistically and clinically significant
improvements in exercise capacity and health status at
three months.
BMJ 2004;329:1209–11
BMJ 2004;329:1209–11
“ Ma è davvero così semplice?”
Compliance
Adherence
La terapia nella malattia cronica
Nella cronicità il paziente deve assumere
e condividere la responsabilità
della terapia e della sua salute
La formazione del paziente ad
un’autogestione consapevole
della malattia diventa parte
integrante della terapia
Adesione e malattie croniche
Nonostante la ricerca clinica abbia raggiunto
risultati rilevanti
per il trattamento e per il controllo delle
patologie croniche,
più del 50% dei pazienti cronici
non riesce ad eseguire correttamente la
terapia consigliata
Che fa il buon dottore?
Good doctors use
both
individual clinical expertise
and
the best available evidence,
and
neither is enough
Sackett DL et al, BMJ 1996; 312: 71-2
E’ necessario l’intervento del paziente
Dying slowly,
painfully and
prematurely
Causes of chronic
diseases
The economic impact:
billions
Si può fare qualcosa su base mondiale?
The global goal
• A 2% annual reduction in chronic disease death
rates worldwide, per year, over the next 10
years.
• The scientific knowledge to achieve this goal
already exists.
Epping-Jordan et al, Lancet 2005
Combined effects of 3 interventions
that each reduce relative risk by 25% (20%)
10,0%
Three
successive
25% RR
reductions
10,0%
9,0%
10.0%
9.0%
8.0%
8.0%
7,5%
8,0%
10.0%
7.0%
7,0%
5,6%
6,0%
Three
successive
20% RR
reductions
5,0%
6.4%
6.0%
4,2%
5.0%
4,0%
4.0%
3,0%
3.0%
2,0%
2.0%
1,0%
1.0%
0,0%
5.4%
0.0%
0
1
2
3
0
Number of interventions
1
2
3
9 out of 10 lives saved:
low and middle income countries
Economic gain: billions
Potential for Europe
• If there are 40 million individuals with a 10
year CV risk of 25%
• In the absence of treatment every year
there will be 1 million strokes and HA
• About half these could be averted (10 year
CV risk 11.25%)
The cardiovascular toll of stress
The cardiovascular
toll of stress
Brotman DJ Lancet 2007;370:1089
Estimated decrease in blood pressure mediated by
non-pharmacological intervention in hypertension
Messerli, Williams, Ritz. Lancet 2007; 370: 591
Potential therapeutic strategies to prevent the
develoment and/or progression of
cardiovascular disease
Blood pressure control Glycemic control
Lipid lowering
Weight loss
Combination treatment in a unique “polypill”?
Combination Pharmacotherapy and Public Health
Research Working Group Report (CDC & US Experts)
• Developing countries may manufacture and distribute
variations of Combination Pharmacotherapy without
waiting for the developed world.
• We think Combination Pharmacotherapy offers the
potential to decrease the incidence of CVD worldwide.
• This expert panel believes that the concept of CP shows
sufficient promise to justify the additional scientific testing
of its potential public health applications.
• Specifically, we recommend further evaluation
(Ann Intern Med. 2005;143:593)
“ Regimens of aspirin, two blood-pressure drugs,
and a statin could halve the risk of death from
cardiovascular disease in high-risk patients.
This approach is cost-effective according to WHO
recommendations, and is robust across several
estimates of drug efficacy and of treatment cost.
Developing countries should encourage the use of
these inexpensive drugs that are currently available
for both primary and secondary prevention.”
ISO Format MENDIS, Shanthi et al. WHO study on Prevention of REcurrences of Myocardial Infarction and
StrokE (WHO-PREMISE). Bull World Health Organ, Nov. 2005, vol.83, no.11, p.820-829. ISSN 0042-9686..
WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE)
ISO Format MENDIS, Shanthi et al. WHO study on Prevention of REcurrences of Myocardial Infarction
and StrokE (WHO-PREMISE). Bull World Health Organ, Nov. 2005, vol.83, no.11, p.820-829. ISSN 00429686..
WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE)
Letter
Polypill debate continues
People will always be sceptical
Letter
"Polypill" to fight cardiovascular disease
Interpretation of trial data is optimistic
Letter
"Polypill" to fight cardiovascular disease
Birthday present was much appreciated
Letter
"Polypill" to fight cardiovascular disease
Now who's playing God?
And so on…
“ Regimens of aspirin, two blood-pressure drugs,
and a statin could halve the risk of death from
cardiovascular disease in high-risk patients.
This approach is cost-effective according to WHO
recommendations, and is robust across several
estimates of drug efficacy and of treatment cost.
Developing countries should encourage the use of
these inexpensive drugs that are currently available
for both primary and secondary prevention.”
RIGHT or WRONG?
“The dogs howl, but the moon
still keeps on shining”
BMJ letter from a medical student
“Now who's playing God ?”
BMJ letter from S. Taylor and A. Konings
A Polypill for Everything ?
Is polypill approach feasible and
effective in preventing
cardiovascular damage?
Ingredients of Polymeal:
Wine (150 ml/day)
Fish (114 g 4 times/week)
Dark chocolate (100 g/day)
Fruit & vegetables (400 g/day)
Garlic (2.7 g/day)
Almonds (68 g/day)
BMJ 2004; 329: 1447
Lifetime effect of Polymeal at age 50
Total life expectancy
Life expectancy free from
CVD
None
+4.8
yrs
35
35
30
30
25
25
Years
Years
40
+6.6
yrs
Polymeal
20
15
20
15
10
10
5
5
0
0
Men
Women
+9.0
yrs
+8.1
yrs
Men
Women
Franco OH et al. BMJ 2004; 329: 1447
“It may be argued that the Polypill is
even more effective, but the Polymeal
promises
to
be
pharmacological,
an
effective,
safe,
and
non-
tasty
alternative for reducing cardiovascular
morbidity and increasing life expectancy
in the general population.”
Franco OH et al. BMJ 2004; 329: 1447
The REACH Study (30.000 pts, 52% donne)
Mc Cullough PA JACC 2002;39:60
CLINIC OR HOME BASED
INTERVENTIONS?
Veramente, io ero sicuro che…….
Reality: 80% of
chronic disease
deaths occur in low
& middle income
countries
Facing illness
and deepening
poverty
Reality: chronic
diseases affect
men and women
almost equally
Reality:
poor and children have
limited choice
The next
generation
Strong et al, Lancet 2005
Burden of disease
IMPATTO SULLE CAUSE
DI MORTE/ SPERANZA DI VITA
Cost effectiveness
COSTO/ANNI DI VITA
GUADAGNATI
Cost utility
Cost benefit
DALY
OGGETTIVO
(anni senza
disabilità)
QALY
SOGGETTIVO
(anni in buona
qualità di vita
percepita)
DENARO/DENARO
Potential therapeutic strategies to prevent the
develoment and/or progression of
cardiovascular disease
Blood pressure control Glycemic control
Lipid lowering
Weight loss
Combination treatment in a unique “polypill”?
“ Regimens of aspirin, two blood-pressure drugs,
and a statin could halve the risk of death from
cardiovascular disease in high-risk patients.
This approach is cost-effective according to
WHO recommendations, and is robust across
several estimates of drug efficacy and of
treatment cost.
Developing countries should encourage the use
of these inexpensive drugs that are currently
available for both primary and secondary
prevention.”