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Enfermedad Cardiovascular, Neumonía y Complicaciones
Prof. Francesco Blasi
Department of Pathophysiology and TransplantationUniversity of Milan, Italy
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Disclosures
• I have accepted grants, speaking and conference invitations from AstraZeneca, Almirall, Bayer, GSK, Novartis, Pfizer, Chiesi, Guidotti-Malesci, Menarini and Zambon
• I have had recent or ongoing consultancy with AstraZeneca, GSK, Mundipharma,Novartis, Almirall, Menarini
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18–34 Years 35–49 Years 50–64 Years ≥65 Years0
100
200
300
400
500
600
700
11 17 2567
28 37 54
138101 85
127
286332
216
326
618
109 101149
290
Healthy
At-Risk 1 Condition
At-Risk 2 Conditions
At-Risk 3 Conditions
High Risk
Inci
denc
e/10
0,00
0
Age
Multiple Comorbidities Further Increase Pneumococcal Pneumonia Risk in Adults
Estimated Annual Incidence of Pneumococcal Pneumonia in the United States in Adults, by Number of Comorbidities
Persons with ≥2 at-risk conditions accounted for 9%–32% of all at-risk adults, depending on age
4
Pelton SI, et al. Presented at ISPPD 2014, Hyderabad, India. OP-390.
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Pneumonia and Cardiovascular events PATHOPHYSIOLOGICAL MECHANISMS
Corrales-Medina. Lancet 2012
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Identification and prevention of cardiovascular events in pneumonia
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T0 T1 T3 T4 T5 T6T2 T7
+
-
CAP
Non-resolving pneumonia
Improvement
Failure
ERDuring hospitalization After discharge
Rehospitalized
ER
C
C
C
C
Cardiovascular events and pneumonia
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Ramirez J. CID 2008; 47:182–7
T0 T1 T3 T4 T5 T6T2 T7
+
-
CAP
ER
On Hospital admission: AMI
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During the hospital course: Failure and AMI
T0 T1 T3 T4 T5 T6T2 T7
+
-
CAP
Non-resolving pneumonia
Failure
ER During hospitalization
Aliberti S. Chest 2008; 134:955–962
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During the hospital course: Improvement and AMI
T0 T1 T3 T4 T5 T6T2 T7
+
-
CAP
Clinical stability
Improvement
ER During hospitalization
Ramirez J. CID 2008; 47:182–7
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The concurrence of pneumonia and a new cardiac event was often unrecognized, especially in the first 12–24 h of hospitalization, resulting in some patients not receiving
cardiac monitoring or anticoagulant therapy.
Musher DM. CID 2007; 45:158–65
Pneumococcal CAP & Cardiac events
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Jasti H. CID 2008; 46:550–6
T0 T1 T3 T4 T5 T6T2 T7
+
-
CAP
Non-resolving pneumonia
Improvement
Failure
ERDuring hospitalization After discharge
Rehospitalized
After Hospital discharge: cardiovascular events
Reason of Rehospitalization
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Reference Year n. Pts Design CVE Heart Failure
Arrhytmias AMI
Muscher 2007 170 In-pts VA RetroSingle
19% 15% 6% 7%
Becker 2007 391 In-pts Retromulti
17% 12% 3% 8%
Ramirez 2008 500 In-pts VA RetroSingle
-- -- -- 6%
Corrales-Medina
2009 206 In-pts VA RetroSingle
-- -- -- 11%
Perry 2011 50,119 In-pts VA RetroMulti ICD
-- 9% 8% 1%
Mandal 2011 4,408 In-pts RetroMulti ICD
-- -- 9% 3%
Corrales-Medina
2012 2,287 In-ptsOut pts
RetroMulti
(PORT)
27%2%
18%1%
6%1%
1%0
Griffin 2013 3,068 In-pts RetroMultiCAPO
12% 4% 8% 2%
Pneumonia and Cardiovascular events State of the Art
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Corrales-Medina VF. Circulation 2012
1343 inpatients and 944 outpatients CAPThe 30-day mortalityCAP: 2.8%CAP + CVE: 15%
Pneumonia and Cardiovascular events IMPACT on MORTALITY
Viasus D. Journal of Infection (2013) 66, 27e33
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Pneumonia and Cardiovascular events RISK FACTORS for CVE
Variable Griffin 2013
Viasus 2013
Corrales-Medina 2012
Age -- 1.78 1.03
Nursing Home 1.8
Hyperlipidemia 2.01
Cardiac Arrhytmias 1.8
CAD 1.5
Hypertension 1.5
CHD/CHF 3.05 4.3
Hypoalbuminemia 2.3
Statins 0.52
PSI 1.02
Septic Shock 1.7
Tachycardia 1.6
RR>30 1.6
Multilobar 1.36
S. aureu 1.61
K. pneumoniae 2.95
S. pneumoniae 1.39
Demographics
Comorbidities
Severity on admission
Pathogen
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From epidemiology to intervention
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From epidemiology to intervention
300mg of aspirin daily for
1 month.
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From epidemiology to intervention
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From epidemiology to intervention
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Protective effect of statins against the development of CAP
From epidemiology to intervention
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Protective effect of statins against the development of CAP
Statin use was significantly associated with reduced mortality in patients
with CAP.
From epidemiology to intervention
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Protective effect of statins against the development of CAP
Statin use was significantly associated with reduced mortality in patients
with CAP.Low quality evidence
From epidemiology to intervention
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KEY POINTS-CVEs in CAP patients could be mediated by plaque related mechanisms (leading to acute myocardial infarction) versus plaque-unrelated mechanisms (leading to arrhythmias and heart failure).-The prevalence of CVEs in CAP varies broadly from 10 to 30%, with a substantial impact of both short and long-term outcomes.
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• Clinical tools that stratify CAP patients according to their risk to develop cardiac complications may be useful for both clinical and research purposes
• Interventions to prevent the development and progression of cardiac complications in high-risk patients with pneumonia and characterise the effect of these strategies on pneumonia-associated morbidity, mortality, health-care utilisation, and costs
KEY POINTS
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