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Richard Horton , Lancet 2005
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“An illness marked by long duration or frequent recurrence”
“A disease lasting indefinitely. “
“A disease that persists for a long time. long time. A chronic disease is one lasting 3 months or more, by the definition of the U.S. National Center for Health Statistics.
Malattia Cronica : tempo…..
“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”
Malattia Cronica : prognosi….
“Chronic diseases generally cannot be prevented by vaccines or cured by medication, nor do they just disappear
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Cause delle malattie cronicheDeterminantisocioeconomiciculturali ,politici,ambientali
GlobalizzazioneUrbanizzazioneInvecchiamentodella popolazione
Fattori di rischiocomuni , modificabili
Dieta incongruaSedentarietàUso di tabacco
Fattori di rischionon modificabili
EtàEreditarietà
Fattori di rischiointermedi
IpertensioneIpotolleranza glucidicaObesitàDislipidemia
MALATTIAMALATTIACRONICACRONICA
Mal CVMal CVDiabeteDiabeteBPCOBPCONeoplasiaNeoplasia
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Preventing chronic diseases: a vital investment — WHO global report. Geneva:
World Health Organization, 2005.
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Preventing chronic diseases: a vital investment — WHO global report. Geneva:
World Health Organization, 2005.
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Strong et al, Lancet 2005
Cardiovascular disease, mainly heart disease, stroke
Cancer Chronic respiratory diseases Diabetes
35 000 000
Did you know??
Chronic diseases
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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
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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.
Booth GL Lancet 2006; 368: 29–36
Diabetes confers an equivalent Diabetes confers an equivalent risk to ageing 15 yearsrisk to ageing 15 years
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Prevalence of Diabetes*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
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%
Czech Rep.
Finland France Germany Hungary ItalyNether-lands
Slovenia ALL
P=0.004
S2 vs. S1 : P=0.21S3 vs. S2 : P=0.02S3 vs. S1 : P=0.001
* Self-reported history of diagnosed diabetes
Euro Heart Survey Programme 2007ESC Quality Assurance Programme to Improve Cardiac Care in Europe
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Risks are increasing
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Prevalence of Obesity*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
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%
Czech Rep.
Finland France Germany Hungary ItalyNether-lands
Slovenia ALL
P=0.0006
S2 vs. S1 : P=0.009S3 vs. S2 : P=0.051S3 vs. S1 : P=0.0002
* Body mass index ≥ 30 kg/m²
Euro Heart Survey Programme 2007ESC Quality Assurance Programme to Improve Cardiac Care in Europe
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Estimated prevalence of GOLD stage 2 or higher COPD
Mannino DM :Lancet 2007; 370: 765–73
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The ARIC Study:Mannino DM:Respir Med 2006; 100: 115
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Cosa e’una riacutizzazione di BPCO dal punto di vista Cosa e’una riacutizzazione di BPCO dal punto di vista clinico?clinico?
Segni e Segni e sintomisintomi
Peggioramento acuto, inatteso, Peggioramento acuto, inatteso, sostenuto… sostenuto…
temperatura frequenza cardiaca stato mentale
Sistemici
dispnea dispnea (respiro corto, rapido) tosse espettorato espettorato purulento purulento
Respiratori
Funzione
tempo
Normali oscillazioni stato clinico
Riacutizzazioni ?
CHEST 2000; 117:398S
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USA & Canada Europa
28%, 50 milioni
38-55%, 266 - 385 milioni
Cina
27%, 130 milioni
Wolf-Maier K et al. Hypertension 2004 JNC 7 2003 Dongfeng G et al Hypertension 2002
prevalenza di ipertensione arteriosa nel mondo: prevalenza di ipertensione arteriosa nel mondo: un’ epidemia incombenteun’ epidemia incombente
1 miliardo di ipertesi
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diastolica
sistolica
Pressione e mortalitàPressione e mortalità
Ischemia cardiaca ictus
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IV=(P≥65/P≤14)*100
242.0
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(da Pulignano G, 2005)
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Sempre più su……….Sempre più su……….
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Number of Cardiovascular Deaths Projected to 2020
Number of Cardiovascular Deaths Projected to 2020
Millions
0
5.000.000
10.000.000
15.000.000
20.000.000
25.000.000
Lower Income Higher Income
20022020
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Si può fare qualcosa?
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160 DIABETICI TIPO 2160 DIABETICI TIPO 2FOLLOW UP 7.8 ANNIFOLLOW UP 7.8 ANNIETA’ MEDIA 55 A.ETA’ MEDIA 55 A.TUTTI MICROALBUMINURICITUTTI MICROALBUMINURICI
Terapia intensiva su tutti iTerapia intensiva su tutti i fattori di rischiofattori di rischio
- 20%- 20%
Gaede P. NEJM 2003;348:383Gaede P. NEJM 2003;348:383
Morte
+ e
venti
card
iova
scola
ri
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Benefici della terapia antipertensiva Benefici della terapia antipertensiva dimostrati nei trials con PA clinicadimostrati nei trials con PA clinica
(riduzione di circa 10 sist./5 dia. mmHg)(riduzione di circa 10 sist./5 dia. mmHg)
––35-40% 35-40%
-20-25%-20-25%-50%-50%
rallentamento progressione IR
Riduzione % del
rischio relativo
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RR=0.64
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BMJ published online 11 Oct 2007;
12 studi , 8307 pazienti
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Stewart S Circulation 2002;105:2861
• 297 pts per 4.2 anni• età media 75 anni• 50% ischemici• 30% diabetici
+ 28%
Home Based InterventionHome Based Intervention
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Authors’ conclusionsExercise 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
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BMJ 2006;332:1379
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“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.”
A U T H O R S ’ C O N C L U S I O N S
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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
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BMJ 2004;329:1209–11
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“ “ Ma è davvero così semplice?”Ma è davvero così semplice?”
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AdherenceAdherenceComplianceCompliance
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La terapia nella malattia La terapia nella malattia cronicacronica
Nella cronicità il paziente deve Nella cronicità il paziente deve assumere e condividere la assumere e condividere la
responsabilità della terapia e della sua salutedella terapia e della sua saluteLa formazione del paziente ad La formazione del paziente ad
un’un’autogestione consapevole della malattia consapevole della malattia
diventa parte integrante della diventa parte integrante della terapiaterapia
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Nonostante la ricerca clinica abbia raggiunto risultati rilevanti
per il trattamento e per il controllo delle patologie croniche,
più del 50% dei pazienti cronicinon riesce ad eseguire correttamente la
terapia consigliata
Adesione e malattie cronicheAdesione e malattie croniche
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Che fa il buon dottore?Che fa il buon dottore?
Good doctors use
both both individual clinical expertise
and the best available evidence,
and
neither is enoughSackett DL et al, BMJ 1996; 312: 71-2
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E’ necessario l’intervento del pazienteE’ necessario l’intervento del paziente
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Dying slowly, painfully and prematurely
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Causes of chronic diseases
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The economic impact: billions
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Si può fare qualcosa su base mondiale?Si può fare qualcosa su base mondiale?
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The global goalThe 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.
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Epping-Jordan et al, Lancet 2005
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10,0%
7,5%
5,6%
4,2%
0,0%
1,0%
2,0%
3,0%
4,0%
5,0%
6,0%
7,0%
8,0%
9,0%
10,0%
0 1 2 3
10.0%
8.0%
6.4%
5.4%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
10.0%
0 1 2 3
Number of interventions
Three successive
25% RR reductions
Three successive
20% RR reductions
Combined effects of 3 interventions that each reduce relative risk by 25% (20%)
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9 out of 10 lives saved: low and middle income
countries
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Economic gain: billions
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Potential for Europe Potential for Europe
• If there are 40 million individuals with a 10 If there are 40 million individuals with a 10 year CV risk of 25%year CV risk of 25%
• In the absence of treatment every year In the absence of treatment every year there will be 1 million strokes and HAthere will be 1 million strokes and HA
• About half these could be averted (10 year About half these could be averted (10 year CV risk 11.25%) CV risk 11.25%)
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The cardiovascular toll of stress
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The cardiovascularThe cardiovascular toll of stresstoll of stress
Brotman DJ Lancet 2007;370:1089
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Estimated decrease in blood pressure mediated bynon-pharmacological intervention in hypertension
Messerli, Williams, Ritz. Lancet 2007; 370: 591
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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”?
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Combination Pharmacotherapy and Public Health Combination Pharmacotherapy and Public Health Research Research WorkingWorking Group Report (CDC & US Experts) 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 We think Combination Pharmacotherapy offers the potential to decrease the incidence of CVD worldwidepotential 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)
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“ “ Regimens of Regimens of aspirin, two blood-pressure drugs, aspirin, two blood-pressure drugs, and a statinand a statin could halve the risk of death from could halve the risk of death from cardiovascular disease in high-risk patients. cardiovascular disease in high-risk patients.
This approach is cost-effective according to WHO This approach is cost-effective according to WHO recommendations, and is robust across several recommendations, and is robust across several estimates of drug efficacy and of treatment cost. estimates of drug efficacy and of treatment cost.
Developing countries should encourage the use of Developing countries should encourage the use of these inexpensive drugsthese inexpensive drugs that are currently available that are currently available for both primary and secondary prevention.”for both primary and secondary prevention.”
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ISO FormatISO Format MENDIS, ShanthiMENDIS, Shanthi et al et al. WHO study on Prevention of REcurrences of Myocardial Infarction and . WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE).StrokE (WHO-PREMISE). Bull World Health Organ Bull World Health Organ, Nov. 2005, vol.83, no.11, p.820-829. ISSN 0042-9686.. , 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)WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE)
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ISO FormatISO Format MENDIS, ShanthiMENDIS, Shanthi et al et al. WHO study on Prevention of REcurrences of Myocardial Infarction . WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE).and StrokE (WHO-PREMISE). Bull World Health Organ Bull World Health Organ, Nov. 2005, vol.83, no.11, p.820-829. ISSN 0042-, Nov. 2005, vol.83, no.11, p.820-829. ISSN 0042-
9686.. 9686..
WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE)WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO-PREMISE)
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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…
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“ “ Regimens of Regimens of aspirin, two blood-pressure drugs, aspirin, two blood-pressure drugs, and a statin could halve the risk of deathand a statin could halve the risk of death from from cardiovascular disease in high-risk patients. cardiovascular disease in high-risk patients.
This approach is This approach is cost-effective cost-effective according to WHO according to WHO recommendations, and is robust across several recommendations, and is robust across several estimates of drug efficacy and of treatment cost. estimates of drug efficacy and of treatment cost.
Developing countries should encourage the use of Developing countries should encourage the use of these inexpensive drugs that are currently available these inexpensive drugs that are currently available for both for both primary and secondary prevention.”primary and secondary prevention.”
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Is polypill approach feasible and
effective in preventing
cardiovascular damage?
A Polypill for Everything ?
“Now who's playing God ?”BMJ letter from S. Taylor and A. Konings
RIGHT or WRONG?“The dogs howl, but the moon
still keeps on shining”
BMJ letter from a medical student
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BMJ 2004; 329: 1447
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)
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Lifetime effect of Polymeal at age 50
Franco OH et al. BMJ 2004; 329: 1447
Total life expectancy Life expectancy free from CVD
0
5
10
15
20
25
30
35
40
Men Women0
5
10
15
20
25
30
35
Men Women
Yea
rs
Yea
rs
None Polymeal
+6.6 yrs
+4.8 yrs +9.0
yrs
+8.1 yrs
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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 an effective, non-
pharmacological, safe, and tasty
alternative for reducing cardiovascular
morbidity and increasing life expectancy
in the general population.”
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The REACH Study (30.000 pts, 52% donne)
Mc Cullough PA JACC 2002;39:60
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CLINIC OR HOME BASED INTERVENTIONS?
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Veramente, io ero sicuro che…….Veramente, io ero sicuro che…….
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Reality: 80% of chronic disease deaths occur in
low & middle income countries
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Facing illness and deepening
poverty
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Reality: chronic diseases affect men and women almost equally
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Reality: poor and children have
limited choice
The nextgeneration
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Strong et al, Lancet 2005
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Burden of disease IMPATTO SULLE CAUSE DI MORTE/ SPERANZA DI VITA
Cost effectiveness COSTO/ANNI DI VITA GUADAGNATI
Cost benefit DENARO/DENARO
Cost utilityCost utilityDALYDALY
QALYQALY
OGGETTIVOOGGETTIVO
SOGGETTIVOSOGGETTIVO
(anni senza (anni senza disabilità)disabilità)
(anni in buona (anni in buona qualità di vitaqualità di vitapercepita)percepita)
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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”?
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“ “ Regimens of Regimens of aspirin, two blood-pressure drugs, aspirin, two blood-pressure drugs, and a statin could halve the risk of deathand a statin could halve the risk of death from from cardiovascular disease in high-risk patients. cardiovascular disease in high-risk patients.
This approach is This approach is cost-effective cost-effective according to WHO according to WHO recommendations, and is robust across several recommendations, and is robust across several estimates of drug efficacy and of treatment cost. estimates of drug efficacy and of treatment cost.
Developing countries should encourage the use of Developing countries should encourage the use of these inexpensive drugs that are currently available these inexpensive drugs that are currently available for both for both primary and secondary prevention.”primary and secondary prevention.”