Recommandé
Recommandé
Contenu connexe
Tendances
Tendances (20)
En vedette
En vedette (13)
Similaire à Prevention is the best treatment
Similaire à Prevention is the best treatment (20)
Plus de drucsamal
Plus de drucsamal (13)
Dernier
Dernier (20)
Prevention is the best treatment
- 1. Prevention is the Best TreatmentPrevention is the Best Treatment Marc A. Pfeffer, MD, PhDMarc A. Pfeffer, MD, PhD Dzau Professor of Medicine, Harvard Medical SchoolDzau Professor of Medicine, Harvard Medical School Cardiovascular Division, Brigham & Women’s HospitalCardiovascular Division, Brigham & Women’s Hospital Boston, MassachusettsBoston, Massachusetts Disclosures: Marc A. Pfeffer, M.D., Ph.D., reports having serves as consultant to Aastrom, Abbott Vascular, Amgen, Cleveland Clinic, Concert, Daiichi Sankyo, Fibrogen, Genzyme, GlaxoSmithKline, Hamilton Health Sciences, Medtronic, Merck, Novartis, Novo Nordisk, Roche, Salix, Sanderling, Sanofi Aventis, Servier, and Teva and having received grant support from Amgen, Celladon, Novartis, and Sanofi-Aventis. The Brigham and Women’s Hospital has patents for the use of inhibitors of the renin-angiotensin system in survivors of MI with Novartis. Dr. Pfeffer’s shares are irrevocably transferred to charity.
- 2. NORMAL No symptoms Normal exercise Normal LV No symptoms Normal exercise Abnormal LV No symptoms Exercise Abnormal LV Symptoms Exercise Abnormal LV with treatment Symptoms not controlled Asymptomatic LV Dysfunction Compensated HF Decompensated Heart failure Refractory Heart Failure Stage A Stage B Stage C Stage D NYHA Class (I–IV) NYHA IV Stage C 2001
- 3. Effects of Treatment on Morbidity in Hypertension VA Cooperative Study Group on Antihypertensive Agents 143 men (DBP 115 to 129 mm Hg), mean follow-up ~18 months, 29 events Placebo group (n=70) HCTZ + Reserpine + Hydralazine HCl group (n=73) Total events 27 2 Deaths (all CV) 4 0 Class A events* 10 0 Other treatment failures 7 1 Class B events† 6 1 CHF 4 0 * Required treatment with known active agents and permanent removal from protocol assigned therapy (nature of events included dissecting aortic aneurysm, sudden death, ruptured AAA, fundi striate hemorrhage and papilledema, CHF, elevated BUN, rehospitalization,VA Cooperative Study Group. JAMA 1967;202(11);1028-33
- 4. 42 Randomized Controlled Trials Low-Dose Diuretics vs Placebo CHD CHF Stroke CVD events CVD mortality Total mortality 0.79 (0.69-0.92) 0.51 (0.42-0.62) 0.71 (0.63-0.81) 0.76 (0.69-0.83) 0.81 (0.73-0.92) 0.90 (0.84-0.96) 0.002 <0.001 <0.001 <0.001 0.001 0.002 Outcome RR (95% CI) p-value Favors low- dose diuretics Favors placebo 0.4 0.6 0.8 1.0 1.2 1.4 Relative Risk 2003
- 5. Antihypertensive Rx CHF SHEP Cooperative Research Group. JAMA 1991;265:3255–64 Dahlöf B et al. Lancet 1991;338:1281–5 SHEP n 2365 2371 Active Placebo Relative risk
- 6. Fatal or Nonfatal Stroke Heart Failure HR = 0.70 (0.49-1.01) HR = 0.36 (0.22-0.58) Target blood pressure 150/80 mmHg The Trial: International, multi centre, randomised double-blind placebo controlled Inclusion Criteria: Aged 80 or more, Systolic BP; 160 -199mmHg + diastolic BP; <110 mmHg Primary Endpoint: All strokes (fatal and non-fatal) 2008
- 7. Lewis EF. JACC 2003;42(8):1446-53 CARE: Multivariable Predictors of Heart Failure
- 8. PEACE: Development of HF Age 65 to <75 years (vs <65) 1.89 (1.4 - 2.5) <0.00 Age ≥75 years (vs <65) 3.15 (2.2 - 4.5) <0.00 Hx of Diabetes 2.10 (1.6 - 2.7) Lewis EF et al. Circulation: Heart Failure 2009;2:209-16 Baseline Characteristics HR (95% CI) p-value
- 9. Placebo n = 228/2223 (10.3%) Simvastatin n = 184/2221 (8.3%) p <0.015
- 10. Stages of HF and treatment options for systolic heart failure Jessup M and Brozena S. N Engl J Med 2003 ICD Risk factor reduction, patient and family education Treat hypertension, dyslipidemia, diabetes. ACE inhibitors (or ARB) in selected patients ACE inhibitors (or ARB) in all patients; Beta blockers in selected patients. 1’ Prevention
- 11. NORMAL No symptoms Normal exercise Normal LV No symptoms Normal exercise Abnormal LV No symptoms Exercise Abnormal LV Symptoms Exercise Abnormal LV with treatment Symptoms not controlled Asymptomatic LV Dysfunction Compensated HF Decompensated Heart failure Refractory Heart Failure Stage A Stage B Stage C Stage D NYHA Class (I–IV) NYHA IV Stage C 2001
- 12. Years following MI 0 2 4 6 8 10 12 14 16 18 20 Cupples et al. The Framingham Study. NIH Publication 1987;87:2703 MI male Cumulativeprobability ofevent The Framingham Heart Study: 1987 Risk of Heart Failure After MI (Age 35 to 94 at Diagnosis) 0 0.1 0.2 0.3 0.4 0.5 MI female Matched male Matched female
- 14. Mortality and CHF MorbidityMortality and CHF Morbidity 1992 The SAVE Trial
- 15. All-Cause Mortality Years ProbabilityofEvent 0 0.05 0.1 0.15 0.2 0.25 0.3 0 1 2 3 0.35 0.4 4 ACE-I Placebo OR: 0.74 (0.66–0.83) ACE-I: 702/2995 (23.4%) Placebo: 866/2971 (29.1%) 4 TRACE Echocardiographic EF £ 35% AIRE Clinical and/or radiographic signs of HF SAVE Radionuclide EF £ 40% 2000 Flather, Yusuf, Kober, et al.
- 16. LV DysfunctionLV Dysfunction (Progressive)(Progressive) MI Asymptomatic Remodeling Symptomatic CHF Sudden Ischemic Sudden Pump failure
- 17. 50 40 30 20 10 0 0 6 12 18 24 30 36 42 48 p=0.0036 Months Mortality (%) Placebo Enalapril Treatment P=NS Prevention 1992 1991
- 18. 2003
- 19. 1 2 3 4 5 14 12 10 8 6 4 2 Follow-Up (Years) % Heart Failure or Death Heart Failure HR Death post-HF = 9.8 (95% CI 7.7 – 13.5) HF: 68 of 243 (28%) died within 3.5 years Vs. No HF: 252 of 3617 (7%) died within 5 years 2003 CARECARE
- 20. 2003
- 21. ICD Risk factor reduction, patient and family education Treat hypertension, dyslipidemia, diabetes. ACE inhibitors (or ARB) in selected patients ACE inhibitors (or ARB) in all patients; Beta blockers in selected patients. 1’ Prevention Stages of HF and treatment options for systolic heart failure Jessup M and Brozena S 2003
- 23. Superior doctors prevent the disease. Mediocre doctors treat the disease before evident. Inferior doctors treat the full blown disease. - Huang Dee: Nai-Ching (2600 B.C. 1st Chinese Medical Text.)
- 24. Stages of HF and treatment options for systolic heart failure Jessup M and Brozena S. N Engl J Med 2003 ICD Risk factor reduction, patient and family education Treat hypertension, dyslipidemia, diabetes. ACE inhibitors (or ARB) in selected patients ACE inhibitors (or ARB) in all patients; Beta blockers in selected patients. 1’ Prevention
- 25. Heart FailureHeart Failure Sustained Hyperfunction · Congenital · Valvular · Hypertension · Idiopathic · Nutritional · Infectious · Autoimmune · Toxic · Infiltrative Loss of Contractile Tissue Ischemic Coronary Artery Disease Myopathic and Interstitial Processes GENETICSGENETICS