il ruolo strategico della fase di cardiologia riabilitativa · il ruolo strategico della fase di...

Il Ruolo Strategico della Fase di Cardiologia Riabilitativa Pompilio Faggiano

U.O. Cardiologia, Spedali Civili - Brescia

STADIO

A

Paziente a rischio di evoluzione verso

l’insufficienza cardiaca senza segni di

cardiopatia strutturale

STADIO

B

Paziente con cardiopatia strutturale

che non ha ancora sviluppato sintomi

di scompenso

STADIO

C

Paziente con sintomi pregressi o

attuali di scompenso associati a

cardiopatia strutturale

STADIO

D

Stadio terminale che richiede strategie

e centri specializzati

PREVENZIONE INNANZITUTTO !

NYHA I

NYHA I, II, III

NYHA IV

Definizione degli stadi A e B dello scompenso cardiaco

• Stadio B:

• Pregresso infarto miocardico acuto

• Cardiopatia ischemica cronica

– (angina cronica stabile

– o rivascolarizzazione pregressa BPAC o PCI),

– stroke o TIA

• Vasculopatia periferica o carotidea subcritica

• Aneurisma Aorta addominale

• Fibrillazione atriale permanente

Durata del Ricovero

nelle UTIC Italiane

Mediana 4 (2-5) giorni Media: 4.2 + 2.7 giorni

STEMI 4 (3-5)

4.4 + 2.6

SCA NSTE 4 (3-6)

4.4 + 2.4

Scompenso 4 (3-6)

4.7 + 3.0

1st component: Clinical assessment and risk stratification

2nd component: Identification and management of CHF –related disease

3rd component: Pharmacological approach

4th component: Non-pharmacological approach

5th component: Exercise training

6th component: Psychological support

Eur J Cardiovasc Prev Rehabil. 2005

1st component:

Clinical assessment and risk

stratification

JACC 1998;31:1591-7

Survival free of cardiac mortality Free of hospital admission for CHF

2nd component:

Identification and management

of CHF–related disease

1. Kaplan Index

2. Individual Disease Severity

3. Charlson Index

4. Geriatric Index of Comorbidity

5. Incalzi index

6. Cumulative Illness Rating Scale (CIRS)

7. Basic Activity Daily Leaving (BADL)

8. Instrumental Activity Daily Leaving (IADL)

9. Barthel Index

10. FIM

11. Mini Mental State Examination (MMSE)

12. Beck Depression Inventory

Functional evaluation in chronic heart failure

Comorbidity

Disability

Comorbidity

Disability

Care needs

3rd component:

Pharmacological approach

Treatment must be tailored according to the individual characteristics present in each patient,…. must be instituted according to guidelines, with adequate doses and modality of administration. Dosages of drugs prescribed should be equivalent to the dosage used in clinical trials: neither a lesser dose, which may be ineffective nor a higher dose, which may induce serious adverse effects, should be administered.

Heart Failure Management

Noncompliance versus medications ranges

from 20% to 58%

Medication and dietary noncompliance is the

major cause of unnecessary hospitalizations

Professional patient counseling and educational (lifestyle modifications) are essential to achieve optimal treatment of HF and to improve outcome

ESC Guidelines 2012

ICAROS: OBIETTIVO 1 le modificazioni della terapia tra Fase Acuta e CR

p<0.0001 p<0.0001 p<0.0001

Ingresso in riabilitazione

Al termine del programma riabilitativo

SANITA’

Performance Measure ACC/AHA

All 4 CP drugs

32.3%

57.1%

4th component:

Non-pharmacological approach

Topics for Patients, Family, and Health Provider Education and Counseling

General counseling 1. Explanation of heart failure and the reason for symptoms

2. The cause or probable cause of heart failure

3. Expected symptoms

4. Symptoms of worsening heart failure

5. What to do if symptoms worsen

6. Self-monitoring with daily weights

7. Explanation of treatment/care plan

8. The role of family/other caregivers in treatment/care plan

9. Clarification of patient and family responsibilities

10. Tobacco cessation

5th component:

Exercise training

Exercise Training in compensated stable CHF pts

improves peripheral vascular, muscular and

metabolic function

improves respiratory and autonomic function

these effects lead to a significant improvement

in exercise tolerance and quality of life

no significant deterioration in central

hemodynamics

attenuation of unfavorable LV remodeling

>VO2max 2.16 ml/kg/min (95% CI 2.82 to 1.49)

1y follow-up

EF < EDV < ESV

Circulation 2007; 49(24): 2329-2336

•RCT ET vs. UC •EF 28±5% •Endurance training 4 weeks

“…significant decrease in the E/E' ratio from 13 ± 1 to 10 ± 1 in young and 14 ± 1 to 11 ± 1 in old…”

Circulation 2011; 58(17): 1780-1792

•RCT ET vs. UC •64 pts, LVEF ≥50%, NYHA II-III •Endurance+resistance training •32 sessions •Up to 70% peakVO2 •3 months follow-up (CPET, TTE, MLWHF)

peak VO2 E/e’ improved

MLWHF improved

•9 RCT (eight in Europe) •395 pts. Training; 406 Controls •Physical Training eight weeks or more •Follow-up three months or more •Intention to treat approach

Mortalità -35% Riospedalizzazione -28%

BMJ 2004; 328(7433): 189

•Hospitalization due to HF: -28% •Independent of LVEF, type of CR, dose of ET

•3,647 pts. •19 RCT up to January 2008 •LVEF ≤45%, NYHA II-III

Adjusted UHT-free survival curves of CR and non-CR patients, based on the

propensity score-adjusted multivariable Cox model (p value refers to multivariable

Cox model). The follow-up started at the time of discharge from the acute-care setting.

Relative Risk of the primary outcome

for CR pts (on propensity score-

adjusted multivariable Cox analysis ):

0.58 (0.34 to 0.99, P =0.04)

J Cardiopulm Rehabil Prev. 2012; 32:71

Exercise training in CHF: mismatch RCT vs. real word

Gradual mobilisation Callisthenics training (Table 4)

Resistance/ strength training of Small muscle groups

(Table 2)

Is patient progressing well ? Stable weight, normal BP, ECG rate, rhythm. Exclude new symptoms

New onset Worsening of

chronic heart failure

No

Optimize pharmacological

therapy

Correct non-CV and CV

precipitating factors

ACUTE HEART FAILURE

Contra-indication to start easy exercise / early mobilisation

(Table 1) ? .

Yes

Intolerance to / instabilization after easy exercise /

early mobilisation ? .

Yes

No

Respiratory training (Table 4)

Absolute or relative contra-indication to

exercise training. (Table 1) ? .

Yes

No

HF patients undergoing Exercise-based Cardiac Rehabilitation in Europe: <20%

ECRIS study. European Cardiac Rehabilitation Inventory Survey. Eur J Cardiov Prev Rehab 2010

Massimo F Piepoli Eur J Cardiovasc Prev Rehab 2010

http://escardio.org/journals/european-journal-cardiovascular-prevention-rehabilitation

Grazie

Exercise training in CHF: mismatch RCT vs. real word

Niederseer D, ESC 2009

176 RCT (1966-2008) vs. EuroHeart Failure Survey / Framingham Heart Survey

CR nello scompenso cardiaco: di quali pazienti stiamo parlando?

THE ITALIAN SURVEY ON CARDIAC REHABILITATION Dati Lombardia – 2008 COMORBILITA’

Quando la riabilitazione nel paziente scompensato rischia di essere un cosmetico

1. Quando non apporta ulteriori benefici rispetto alla usual care 2. Quando si trasferiscono acriticamente nella vita reale i dati

ottenuti dalle casistiche dei grandi trial 3. Quando non si colgono pienamente le dinamiche di rischio

cardiovascolare/comorbilità/disabilità della propria popolazione di riferimento

4. Quando non si appronta una strategia di mantenimento nel medio-lungo periodo

5. Quando non si considera (e si rende potenzialmente operativo) l’intero “arsenale” a disposizione

Exercise training in HF: New modalities

Combined aerobic / strength

Respiratory

High intensity aerobic training

Tai Chi

Maeng DANAMI-2 Am J Cardiol 2010 Ng HORIZON EHJ-ACVC 2014

FE < 40%

I predittori di rimodellamento ventricolare sinistro

Deceleration time Mitral regurgitation

GISSI-3 Echo Substudy Am Heart J 2001

Temporelli JACC 2004 Person BMJ 2011

Torabi et al. Eur Heart J 2008

60% recurrent at follow up

Definition of HF = use of loop diuretics for signs of fluid retention or breathless

BNP

NT-pro-BNP

Mod. da Velasquez Eur J Heart Fail 2003

Il problema della diagnosi di scompenso cardiaco nelle SCA

Loop diuretics use

- Prevenzione

- Ottimizzazione terapeutica (farmacologica

e non farmacologica)

quindi

- Stabilizzazione/rallentamento della

progressione

- Mantenimento e Recupero della capacità

funzionale

- Miglioramento qualità di vita

- Miglioramento prognosi

Gli approcci farmacologici “imprescindibili”

1) controllo della frequenza cardiaca

2) prevenzione del rimodellamento

3) prevenzione della restenosi/trombosi

4) Stabilizzazione della placca/controllo dell'assetto lipidico

5) Trattamento dell’ischemia residua

220

210

200

190

4 12 0 Month

En

d-d

iasto

lic v

olu

me (

cc) P = 0.025 160

155

150

140

4 12 0 Month

P = 0.019

145

En

d-s

ysto

lic v

olu

me (

cc) 0.40

0.30

0.20

0.10

4 12 0 Month

Eje

cti

on

Fra

cti

on

0

Etiology, % Ischemic: 76.7% (SOLVD echo substudy, n=301) 79.0% (SOLVD, n=6496)

Greenberg B et al. Circulation 1995

Placebo n = 130 130 142

Enalapril n = 128 127 137

Placebo n = 130 130 142

Enalapril n = 128 127 137

ACE Inhibition Prevents Remodelling: SOLVD – Echocardiographic Substudy

Hospital Discharge 1-year follow-up

Arnold et Al. JACC 2014 …..most patients hospitalized with an AMI were routinely

discharged on secondary prevention medications at

doses substantially below the levels proven to be efficacious in

clinical trials. These doses were infrequently increased as

outpatients, even after 1 year.

…… being on a target medication dose at discharge was the

strongest predictor of being on a target dose at follow-up.

……clinicians should attempt to maximize the doses of

secondary prevention therapy during the index hospital stay and

to uptitrate these medications during outpatient follow-up.

ICAROS: OBIETTIVO 1 le modificazioni della terapia dopo la CR

SANITA’

ICAROS: OBIETTIVO 1 I target di prevenzione secondaria dopo la CR

SANITA’

Review/Metanalisi

RCT Training fisico in CHF

RCT CR in CHF

M Piepoli

Anti-inflammatory effect of Exercise Training in CHF

Gielen S. JACC 2003

train

ing

tr

ain

ing

training

Copyright ©1996 American Heart Association

Piepoli, M. et al. Circulation 1996;93:940-952

Effect of Exercise training on the Contribution of Muscle metaboreflex to Exercise in Heart Failure vs Controls

Physical Training

Detraining

Patwala, JACC 2009

Patwala, JACC 2009

Peak VO2

NYHA class

•2,331 pts. •82 sites (US, Canada, France) •LVEF ≤35%, NYHA II-IV •RCT ET vs. UC •Randomization 2003-2007 •ET group: 36 supervised sessions (up to 35m/session at a 70% HR reserve) plus home-based ET •Exclusion criteria: major comorbidities, recent (<6w) MACE, planned procedure, regular PT, device limiting HR control

•Adjusted for HF etiology

•Adjusted for CPET test, LVEF, Depression, AF -11%

JAMA 2009; 301(14): 1439-1450

Belardinelli, JACC 2012

Massimo F Piepoli

Intolleranza/Controindicazioni?

Gradual mobilization Callisthenics Resistance/Strength training of small muscle groups Respiratory Training

grazie


1. Quando non apporta ulteriori benefici rispetto alla usual care

SOLVD-T 1991

CIBIS/MERIT-HF 1999 EMPHASIS

2011



ottenuti dalle casistiche dei grandi trial


THE ITALIAN SURVEY ON CARDIAC REHABILITATION Dati Lombardia – 2008 PRESTAZIONI DURANTE CR

CHF+

CHF-

S1

61%

52,5%

45

50

55

60

65

Prevalenza disabilità grave al WT



2013, in press


DATI SDO 2010

IN RIABILITAZIONE: •DRG 127 a livello nazionale: degenza media 19.2 gg





4. Quando non si considera (e si rende potenzialmente operativo) l’intero “arsenale” a disposizione



VALUTAZIONE FUNZIONALE

THE ITALIAN SURVEY ON CARDIAC REHABILITATION Dati Lombardia – 2008



TIPOLOGIA DI TRAINING

Logo struttura Etichetta pz.PROGRAMMA CARDIOVASCOLARE RIABILITATIVO INDIVIDUALE (pri)

1. Strumenti/interventi per conduzione PRI barrare 2. Figure coinvolte barrare

Monitoraggio telemetrico Cardiologo

Monitoraggio multiparametrico Angiologo

Medicazioni standard decubiti/ferite chirurgiche Cardiochirurgo

Medicazioni avanzate Chirurgo Vascolare

Misure di prevenzione decubiti Fisiatra

Misure di prevenzione cadute Internista/Geriatra

Gestione catetere vescicale Neurologo

Gestione cateteri venosi periferici Pneumologo

Gestione catetere venoso centrale Diabetologo

Ossigenoterapia Nefrologo

Gestione presidi/device/ausili personali Infermiere

Adattamento ventiloterapia Fisioterapista

Training fisico cardiovascolare Psicologo

FKT per disabilità specifica Dietista

Esami ematochimici Assistente sociale

ECG Altre figure

Ecocardiogramma

ECG dinamico

Monitoraggio PA 24h

Marcatori cardiaci 3. Documentazione barrare

CT/RMN cardiaca e/o vascolare Diario medico giornaliero

Walking test Scheda terapia

Test ergometrico Cartella infermieristica

Test cardiopolmonare Cartella riabilitativa

Scintigrafia miocardica Referti esami diagnostici

TWA Tracciati di monitoraggio

Test fenilefrina/Heart Rate Variability/Potenziali tardivi Moduli consulenze

Tilt test Altro

Ultrasonografia vascolare periferica

Studio elettrofisiologico

Cateterismo cardiaco destro

Consulenze specialistiche Medico Responsabile del PRI

Consulenza psicologica Data

Consulenza nutrizionale

Utilizzo di altre scale funzionali Firma

Utilizzo di scale per il dolore

Valutazione psicometrica

Valutazione cognitiva Altre figure responsabili del pri

Counselling/Educazionale individuale Data

Counselling/Educazionale di gruppo

Consegna materiale educazionale Firma

Contatto con servizi socioassistenziali territoriali

Decreto Direzione Generale Sanità n° 2886

del 24 marzo 2010

SOLVD-T 1991

CIBIS/MERIT-HF 1999 EMPHASIS

2011

- Prevenzione



quindi


progressione


funzionale



- Prevenzione



quindi


progressione


funzionale



LE STRATEGIE

1) Classe Killip max

2) Frazione di eiezione <40%

3) Frazione di eiezione >40% <45% con:

a) Pattern riempimento diastolico restrittivo

b) Insufficienza mitralica > 1

c) WMSI elevato e ventricolo non dilatato

4) Importante variazione BNP

5) Uso di diuretici dell’ansa

6) Arteriopatia periferica

7) Storia di angina o pregresso infarto miocardico

8) Malattia coronarica multivasale/TC

9 Rivascolarizzazione incompleta o subottimale

10) Non rivascolarizzazione

Check list da inserire nella cartella clinica

Clinical use of cardiopulmonary exercise testing in HF

Evaluation of dyspnea on exertion

Evaluation of patients with cardiovascular disease

Evaluation of patients with pulmonary disease

Evaluation of impairment / disability

Evaluation of fitness

To determine of therapeutic effectiveness

Assessment of responses to training

As part of rehabilitation program - exercise prescription

Selection of patients for cardiac transplantation

“….has been shown to represent a clinically

important and meaningful difference for the

patient…”

European Journal of Heart Failure 2006; 8(8): 841-850.

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