Richard Horton , Lancet 2005

“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

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

Preventing chronic diseases: a vital investment — WHO global report. Geneva:

World Health Organization, 2005.

Preventing chronic diseases: a vital investment — WHO global report. Geneva:

World Health Organization, 2005.

Strong et al, Lancet 2005

Cardiovascular disease, mainly heart disease, stroke

Cancer Chronic respiratory diseases Diabetes

35 000 000

Did you know??

Chronic diseases

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

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

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

Risks are increasing

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

Estimated prevalence of GOLD stage 2 or higher COPD

Mannino DM :Lancet 2007; 370: 765–73

The ARIC Study:Mannino DM:Respir Med 2006; 100: 115

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

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

diastolica

sistolica

Pressione e mortalitàPressione e mortalità

Ischemia cardiaca ictus

IV=(P≥65/P≤14)*100

242.0

(da Pulignano G, 2005)

Sempre più su……….Sempre più su……….

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

Si può fare qualcosa?

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

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

RR=0.64

BMJ published online 11 Oct 2007;

12 studi , 8307 pazienti

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

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

BMJ 2006;332:1379

“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

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

BMJ 2004;329:1209–11

“ “ Ma è davvero così semplice?”Ma è davvero così semplice?”

AdherenceAdherenceComplianceCompliance

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

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

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

E’ necessario l’intervento del pazienteE’ necessario l’intervento del paziente

Dying slowly, painfully and prematurely

Causes of chronic diseases

The economic impact: billions

Si può fare qualcosa su base mondiale?Si può fare qualcosa su base mondiale?

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.

Epping-Jordan et al, Lancet 2005

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%)

9 out of 10 lives saved: low and middle income

countries

Economic gain: billions

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%)

The cardiovascular toll of stress

The cardiovascularThe cardiovascular toll of stresstoll of stress

Brotman DJ Lancet 2007;370:1089

Estimated decrease in blood pressure mediated bynon-pharmacological intervention in hypertension

Messerli, Williams, Ritz. Lancet 2007; 370: 591

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”?

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)

“ “ 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.”

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)

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)

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…

“ “ 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.”

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

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)

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

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.”

The REACH Study (30.000 pts, 52% donne)

Mc Cullough PA JACC 2002;39:60

CLINIC OR HOME BASED INTERVENTIONS?

Veramente, io ero sicuro che…….Veramente, io ero sicuro che…….

Reality: 80% of chronic disease deaths occur in

low & middle income countries

Facing illness and deepening

poverty

Reality: chronic diseases affect men and women almost equally

Reality: poor and children have

limited choice

The nextgeneration

Strong et al, Lancet 2005

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)

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”?

“ “ 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.”