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