journée d’automne de la ssc - schweizerische ...€¦ · (paired-samples t-test) sedentarity ......

Prof. FranProf. Franççois Mach, MDois Mach, MDDivison of CardiologyDivison of Cardiology

Geneva University HospitalGeneva University [email protected]@hcuge.ch

www.cardiologywww.cardiology--geneva.chgeneva.ch

Bern, le 25 novembre 2010Bern, le 25 novembre 2010

PrPréévention dvention déépistage:pistage:

JournJournéée de d’’automne de la SSCautomne de la SSC

Office FOffice Fééddéérale de la Statistique rale de la Statistique NeuchâtelNeuchâtel 20062006

Health in SwitzerlandHealth in Switzerland

LipidsLipidsHypertHyperteensionnsion

AgeAge

SmokingSmoking

ObesitObesityy

NutritionNutrition

Familial HistoryFamilial HistorySedentaritySedentarity

GenderGender

GeneticGenetic

DDiabetesiabetes

Can be modifiedCan be modified

Can not be modifiedCan not be modified

Cardiovascular risk factorsCardiovascular risk factorsCardiovascular risk factors

Am J Public Health 2005

Male 35-74 year oldData from the “Bus santé” Geneva

Cardiovascular risk factorsCardiovascular risk factorsCardiovascular risk factors

LancetLancet 20020044;;364364::937937

Cardiovascular risk factors for MICardiovascular risk factors for MICardiovascular risk factors for MI

8080--90% of acute 90% of acute MI are MI are

predictable !predictable !

Lancet 2004;364:937

CV Risk Factors & AtherosclerosisCVCV Risk Factors & Risk Factors & AthAtheerosclroscleerosrosisis

p=0.0001p=0.0001

Durée de suivi(ans)

Durée de suivi(ans)

11 55 1010 1515 2020

100%100%

90%90%

80%80%

70%70%

Prob

abilit

éde

surv

iePr

obab

ilité

de su

rvie

FC <60 bpmFC <60 bpm

60< FC <80 bpm60< FC <80 bpm

80 < FC <100 bpm80 < FC <100 bpm

FC >100 bpmFC >100 bpm

19’386 sujets - “Check-up”

FC par ECG

Suivi moyen: 18.2 ans

19’386 sujets - “Check-up”

FC par ECG

Suivi moyen: 18.2 ans

Heart rate and life expectancy within general population

• 5713 men

N Eng J MedN Eng J Med 20052005;352:1951;352:1951

• Mean follow.up 23 years

Heart rate and life expectancy within general population

•24 913 patients

Patients with coronary disease

Eur Heart JEur Heart J 20052005;26:867;26:867

•Median follow-up was 14.7 years

Heart rate and life expectancy within patients

MYO

CA

RDIA

L O

MYO

CA

RDIA

L O

22D

EMA

ND

DEM

AN

D

DIA

STO

LIC

TIM

ED

IAST

OLI

C T

IME

HEART RATEHEART RATE

O2 consumptionDiastolic time

Heart rate is a risk factor for myocardial ischemia

Predisposition Presymptomatic Symptomatic

Primary

Secondary

Tertiary

Prevention

Internist 2008;49:146

Cardiovascular PreventionCardiovascular Prevention

Tabacco and and Cardiovascular RiskTabacco and and Cardiovascular Risk

Am J Public Health 2007;97:2035

Observed number of hospital admissions for acute myocardial infarction and predicted number of hospital admissions in the absence of a comprehensive smoking ban,

by month: New York State, 2002-2004

Tabacco and and Cardiovascular RiskTabacco and and Cardiovascular Risk

LipidsLipidsHypertHyperteensionnsion

AgeAge

SmokingSmoking

ObesitObesityy

NutritionNutrition

Familial HistoryFamilial HistorySedentaritySedentarity

GenderGender

GeneticGenetic

DDiabetesiabetes

Can be modifiedCan be modified

Can not be modifiedCan not be modified

Cardiovascular risk factorsCardiovascular risk factors

Cardiovascular risk factorsCardiovascular risk factors

IntraIntra--abdominal obesity (adiposity)abdominal obesity (adiposity)and cardiovascular risk factorsand cardiovascular risk factors

115 cm115 cm

2.3 mmol/l2.3 mmol/l



Perform physical activity in daily life…Perform physical activity in daily lifePerform physical activity in daily life……

• Do not use elevators but only escalators at working place

• For 12 weeks

Sedentarity - InterventionSedentarity - Intervention

Effects on the use of escalators instead of elevators at workingplacefor better cardiovascular primary prevention:

Intervention within employee of the Geneva University Hospital

<0.001+ 0.22V02 max (l/min)

+17.25

+ 3.21- 1.77

- 1.86- 0.21

- 0.35- 1.67

- 0.18- 0.55

Mean diff.

<0.001Stairs (Floors -up /day )

<0.001V02 max (ml/kg/min)

0.03Diastolic BP (mmHg )

0.07Systolic BP (mmHg )

0.2FFM (Kg)

0.03Fatmass (Kg)

<0.001Waist circ (cm)

0.04BMI (Kg/m2 )

0.02Weight (Kg)

p

<0.001+ 0.22V02 max (l/min)

+17.25

+ 3.21- 1.77

- 1.86- 0.21

- 0.35- 1.67

- 0.18- 0.55

Mean diff.

<0.001Stairs (Floors -up /day )

<0.001V02 max (ml/kg/min)

0.03Diastolic BP (mmHg )

0.07Systolic BP (mmHg )

0.2FFM (Kg)

0.03Fatmass (Kg)

<0.001Waist circ (cm)

0.04BMI (Kg/m2 )

0.02Weight (Kg)

p

Pre and post intervention analysis(paired-samples t-test)


Prédisposition Présymptomatique Symptomatique

Primaire

Secondaire

Tertiaire

Prévention

Internist 2008;49:146

Cardiovascular PreventionCardiovascular Prevention

ELIPS: a MultiELIPS: a Multi--dimdimeensionansionall preventpreventiion on pprogram after ACrogram after ACSS

Phase 1

Inclusion before

ELIPS

(n=1500, control group)

Phase 2

Inclusion after

ELIPS

(n=1500, treated group)

Bio-clinical trial (12 months Follow-Up)

Quality trial(3 weeks after inclusion)

Bio-clinical trial (12 months Follow-Up)

Quality trial(3 weeks after inclusion)

ELIPS®

I° Endpoint: CV Death, MI or recurrent ischaemia, CVA, TIA or lower limb ischaemia

2° Endpoint: each 1° Endpoint, Bio-clinical : BMI ↓, LDL ↓, CRP ↓, HDL↑

Inclusion: ACS

ZH, BE, LS, GE: SPUM project

Program Start December 2010Program Start December 2010

www.spum-acs.ch

La réadaptation cardiaque est un programme multidisciplinaire bien défini

• Évaluation médicale

• Prise en charge des facteurs de risque

– Diabète, obésité, tabagisme, dyslipidémie, HTA

• Conseils nutritionnels

• Interventions psycho-sociales

• Conseils en activité physique

• Entraînement physique

Circulation 2007;115:2675

Les bénéfices cliniques de la réadaptation cardiaque sont bien établis

• ↘ 20% mortalité totale

• ↘ 26% mortalité cardiaque

• Recommandation de classe I (ACC/AHA)

– Maladie coronarienne et insuffisance cardiaque chronique

Am J Med 2004;16:682Circulation 2007;115:2675

La réadaptation cardiaque est habituellement divisée en 3 phases

• Phase I: intra-hospitalière

• Phase II: précoce après un évènement CV (3-6 mois)

• Phase III: au long cours

World Health Organization 1980

Plusieurs indications à la réadaptation cardiaque sont reconnues

• Infarctus du myocarde / syndrome coronarien aigu

• Revascularisation percutanée / chirurgicale

• Chirurgie valvulaire

• Transplantation cardiaque

• Insuffisance cardiaque chronique

• Insuffisance artérielle périphérique

J Am Coll Cardiol 2007;50:1400

3 modalités de réadaptation cardiaque de phase II sont possibles

• Dans un centre ambulatoire

• Dans un centre stationnaire

• À domicile

Dalal HM et al. BMJ 2010;340:5631

Ø différence significative en terme d’amélioration de la capacité

fonctionnelle entre les 2 programmes

L’introduction de ce type de programmes en Suisse est probablement moins

adaptée • Réseaux de soins et de transport très denses• Programmes de réadaptation plus intensifs 5x/sem• Système de soins encore solvable…

…mais ils pourraient être utiles dans certains cas:

• Patients indépendants et instruits• Patients âgés• Comme relais vers la réadaptation de phase III

Mieux rMieux rééspirerspirer……Manger mieuxManger mieux……

Bouger plusBouger plus……

Conclusions/MessagesConclusions/Messages

“prevention is better than cure”“prevention is better than cure”

Cardiovascular protection should start as soon as possibleCardiovascular protection should start as soon as possible……

EuroPrevent Congress 2011 EuroPrevent Congress 2011 EuroPrevent Congress 2011

International Congress Center Geneva, Geneva, April 14-16, 2011 International Congress Center Geneva, International Congress Center Geneva, Geneva, April 14Geneva, April 14--16, 2011 16, 2011

MerciMerciMerci

Prof. François Mach, MDCardiology Division

Department of Internal MedicineGeneva University [email protected]

www.cardiology-geneva.ch

Réunion d’automne SSCBern, le 25 novembre 2010Bern, le 25 novembre 2010

12 essais cliniques randomisés comparant une réadaptation à domicile versus dans

un centre• Population étudiée:

– Patients ayant présenté un infarctus du myocarde, un angor, une insuffisance cardiaque ou une revascularisation coronarienne

• Programmes de réadaptation: – 8 complets (exercice + éducation et/ou prise en charge

psychologique), 4 seulement exercice– Durée 6 à 25 semaines, 1 à 5x/semaine, 25 à 60 min

Comparaison des différents points d’aboutissement entre les 2 types de

programmes

No études Modèle d’estimation Estimation de l’effet

(95% CI) P

Capacité fonctionnelle 14 Diff. moy. standard -0.11 (-0.35 à 0.13) 0.36

TA systolique 9 Différence moyenne -0.51 (-4.63 à 3.61) 0.77

TA diastolique 7 Différence moyenne 1.85 (0.74 à 2.96) 0.001

Cholestérol total 7 Différence moyenne 0.13 (-0.05 à 0.31) 0.16

HDL-C 5 Différence moyenne -0.06 (-0.11 à -0.02) 0.004

LDL-C 4 Différence moyenne 0.15 (-0.01 à 0.31) 0.06

Tabagisme 5 Risque relatif 1.02 (0.76 à 1.37) 0.88

Suivi complet 10 Ratio de risque 1.00 (0.97 à 1.04) 0.83

Mortalité 4 Risque relatif 1.31 (0.65 à 2.66) 0.45

Coûts 4 Pas de différence significative

La réadaptation à domicile a étédéveloppée chez des patients post-IM

à bas risque à partir de 1980• Pour les patients ne pouvant pas participer en groupe (éloignés,

âgés, travailleurs indépendants, minorités ethniques…)

• Populaire actuellement surtout en Grande-Bretagne

• « The Heart Manual »– Livre / journal de bord / CD relaxation / CD-ROM information– Visite infirmière initiale 1 h– Programme de 6 semaines– Suivi téléphonique 1x/sem

Circulation 1984;70:645Int J Cardiol 2007;119;202

ACS: a poor prognosisACS: a poor prognosis

STEMI NSTEMI

30-Day Mortality 8 % 6 %

1-Year Mortality 9 % 11.6 %

GRACE Registry. Am J Cardiol 2004;93:288Eur Heart J 2007;28:1409

ACS: a poor prognosisACS: a poor prognosis

• Why is the recurrence rate so high ?

Because of under use of recommended therapy by the physician

Because atherosclerosis is a chronic disease with a complex treatment

Because of the lack of therapeutic adhesion by the patient

Patient-level intervention

Health care providers-level intervention Health care providers-level intervention

System-level interventionSystem-level intervention

Auer R. Circ 2008;

26 studies; 37'585 patients with one year follow up

How to improve therapeutic adherence?How to improve therapeutic adherence?

Time

Insulin1921

Antibiotics1945

Patient education1972

diabetesTE has optimalized application of

biomedical advances

Mor

talit

y

Courtesy: A. Golay

Multi-dimensional

ACS: a poor prognosis

To improve quality of care of patients with an ACS

To improve quality of information and education

To improve therapeutic adhesion

TO IMPROVE OUTCOME

Why ELIPS ?Why ELIPS ? ELIPS

How to improve therapeutic adhesion:How to improve therapeutic adhesion:

By motivatingBy motivating

By educatingBy educating

ACS: a poor prognosisELIPSELIPS ELIPS

The patient experience:The patient experience:Acute coronary syndromeAcute coronary syndrome

•• Sudden eventSudden event•• Rapid therapeutic Rapid therapeutic

responseresponse•• Impressive technical Impressive technical

resourcesresources•• Immediate perceptible resultsImmediate perceptible results

Educational intentions:Educational intentions:manage amanage a chronic diseasechronic disease

•• Make the patients aware of Make the patients aware of their diseasetheir disease

•• Promote lifestyle changesPromote lifestyle changes•• Improve adherence to Improve adherence to

treatmenttreatment

The TPE challenge The TPE challenge «« acute acute -- chronicchronic »»

TPE: Therapeutic Patient Education

PassivePassive ActiveActive

52

Tools of CommunicationTools of Communication

Multi-dimensional

1st of October 20101st of October 2010

DVD

For patientsFor Healthcare providers

Multi-dimensional

1st of October 20101st of October 2010

web

Multi-dimensionalMobile App

www.elips.ch

1) Tools of information1) Tools of information comprehension comprehension and motivation of the patient by using uniformand motivation of the patient by using uniformmessages: messages: PatientPatient--level interventionlevel intervention

ELIPS

For Hospitals and outpatient practices

2) Motivational Interviews2) Motivational InterviewsA new technique of communication for A new technique of communication for Health Care Providers: Health Care Providers: HCPHCP--level interventionlevel intervention

b) A training course in motivational interviews (2 days)

A structured learning process for HealthCare Providers including:

a) An e-learning to approach this new technique of communication (90 min)

c) A control of the process on site by a specialized nurse

For Hospitals

ELIPS

3) Standardization of therapy for patients with ACS3) Standardization of therapy for patients with ACS

1) A critical pathway for hospitals

2) A discharge card of treatment for patients and outpatient practices

TO IMPROVE QUALITY OF CARE

ELIPS

Tools offered to GPs, internists, cardiologists for their patients

Novel information tools about ACS and Atherosclerosis:ELIPS:

- a standardized discharge card of treatment- a website, an e-learning- an educational DVD- information flyers & wall chart

and …..- symposiums of information for outpatient and physicians organized by local university hospitals

3) Standardization of therapy for patients with ACS3) Standardization of therapy for patients with ACSELIPS

ACS: a poor prognosisThank youThank youDr Lukas AltwegDr Reto AuerDr Vincent BarthassatDr David CarballoDr Sebastian CarballoPr Jean-Claude ChevroletDr Pierre ChopardMme Suzanna ConvertProf Jacques CornuzDr Pascal GachePr Alain GolayMme Christelle GuillaumeDr Pierre-Frédéric KellerDr Roland KlingenbergPr Thomas LuscherPr François MachDr Christian Matter

Mme Suzanne MuellerPr Thomas PernegerDr Lorenz RaeberMme Agnies ReffetMme Ariel Richard-ArlaudDr Nicolas RodondiDr Marco RoffiM. Allen SavardMme Florence ScherrerM. Franck SchneiderM. Philippe SigaudDr Johanna SommerPr Pierre VogtPr Gérard WaeberPr Stephan Windecker

ELIPS

La fondation GEcor

Abbott VascularAstraZenecaBiotronikBoston ScientificBristol-Myers SquibbCordisDaichii-SankyoEli LillyEssexGE-Healthcare MedicalGlaxo Smith KlineInvatec

MSDPfizerSanofi-aventisServierSt. Jude MedicalTakeda

ACS: a poor prognosisThank youThank you ELIPS

♀♀

0Patients (%)

♂♂

20 40 60


Framingham Heart Study (n=5144)

Infarctus ou mort subite comme 1ère présentation

Premier événement peut être le dernier !Premier Premier éévvéénement peut être le dernier !nement peut être le dernier !

Multi-dimensionalE-learning

ACS: a poor prognosisPatient

s (%

) 15.2

0.0

5.0

10.0

15.0

20.0

Cardiovascualr Mortality / MI / Stroke

Established atherosclerotic arterial disease

5.3

at risk of atherothrombosis

1 patient out of 7 will experience a

recurrence of a CV event (MI, Stroke,

Cardiovascular Death, angina, PAD) within the next 12 months following an ACS.

N=68’236 patients

Steg P.G. JAMA. 2007;297:1197‐1206.

ACS: a high rate of reccurent CV event

PolypillPolypillPolypill

The Lancet Published online March 30, 2009

The Lancet Published

PolypillPolypill

PolypillPolypill

The Lancet Published

LancetLancet 20020044;;364364::937937

Cardiovascular risk factors for MICardiovascular risk factors for MICardiovascular risk factors for MI

Limitations avouées et non avouées

• Patients à bas risque, sécurité non établie pour IC par ex.• Hétérogénéité des patients et des programmes

• Réadaptation en centre semble supérieure si programme intensif

• Réadaptation cardiaque validée par programmes en centre

• Difficulté de motivation hors d’un groupe• Pas de supervision étroite (contrôles/corrections)• Bon niveau d’éducation nécessaire

Mensonges et Propagande

Women

0Patients (%)

Men

20 40 60


Framingham Heart Study (n=5144)

MI or SD as 1st Presentation

PreventionPreventionPrevention

Primary PreventionPrimary Prevention Secondairy PreventionSecondairy Prevention

Cardiovascular eventCardiovascular eventDiagnosois of atherosclerosisDiagnosois of atherosclerosis

Atherosclerosis Atherosclerosis –– Dynamic ProcessDynamic Process

Stress & Cardiac Rythm

journée d’automne de la ssc - schweizerische ...€¦ · (paired-samples t-test) sedentarity ......

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