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Key facts regarding CVD treatments: Using the evidence base in modelling

Cardiovascular Epidemiology and Epidemiological Modelling. Key facts regarding CVD treatments: Using the evidence base in modelling. Martin O’Flaherty Simon Capewell Division of Public Health University of Liverpool. A Simplified model of the Clinical phase of Atherosclerosis. Sudden Death.

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Key facts regarding CVD treatments: Using the evidence base in modelling

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  1. Cardiovascular Epidemiology and Epidemiological Modelling Key facts regarding CVD treatments:Using the evidence base in modelling Martin O’Flaherty Simon Capewell Division of Public Health University of Liverpool

  2. A Simplified model of the Clinical phase of Atherosclerosis Sudden Death At risk Acute Myocardial Infarction Death Heart Failure MI Survivors Unstable Angina Chronic Angina Stroke

  3. Key patients groups • Acute Coronary Syndromes • Stable Angina • Heart Failure • Stroke • Peripheral Arterial disease

  4. Strategies to Manage CVD Disease • Aims: • Prevent clinical disease • Postpone disease progression • Decrease mortality • Increase Quality of Life

  5. Acute Coronary Syndromes • Complex situation: • Definitions keep changing for clinical purposes. • Epidemiological definitions: • Circulation. 2003 Nov 18;108(20):2543-9 • EuroCISS: http://www.cuore.iss.it/eurociss • Groups (Clinical) • Acute Myocardial infarction • STEMI (ST elevation Myocardial Infarction) • NSTEMI (Non ST elevation Myocardial infarction • Unstable angina

  6. Acute myocardial infarction • Atherosclerotic plaque rupture leading to a sudden occlusion of a coronary artery • Myocardial muscle loss. • Host of complications: • Electrical: arryhtmias • Mechanical: heart failure and cardiogenic shoc • Therapy: • Type of AMI (STEMI vs NSTEMI) is critical to guide decisions • Decrease size of infarct • Treat complications • Stabilize atherosclerotic plaque to prevent further ischemic events • Efficacy outcomes: • Rates of major cardiovascular events: • Death • Recurrent AMI • Refractory ischaemia • Stroke. • Safety outcomes: • Rates of major bleeding

  7. 7% 15% 4% 32% 31% Ongoing debate PCI vs. thrombolysis

  8. Unstable Angina • Atherosclerotic plaque unstable, producing inflammatory and thrombotic phenomena causing myocardial ischemia but not myocardial muscle death. • Definition: • New symptoms • Recent change in the stable anginal symptoms pattern • No evidence of myocardial necrosis. • Therapy: • Avoid progression to AMI • Stabilize atherosclerotic plaque to avoid progression of ischemia (eg: to AMI) • Revascularization strategies based on risk of future events and anatomy • Efficacy outcomes: • Rates of major cardiovascular events: • Death • AMI • Refractory ischaemia • Re admission to hospital • Safety outcomes: • Rates of major bleeding

  9. 33% 9% 32% 32% 43%

  10. Chronic Angina • Progressive occlusion by an atherosclerotic plaque, causing myocardial ischemia. • Definition: • Clinical definition based on anginal symptoms, pattern and duration • Several validated questionnaires (Rose questionnaire) • Therapy: • Avoid ischemic events (secondary prevention) • Symptom relief • Efficacy outcomes: • Rates of major cardiovascular events: • Death • AMI/UA • Symptoms and Quality of Life • Safety outcomes: • Rates of major bleeding

  11. Secondary Prevention in CVD patients • Who: • Every patient with Clinical CHD (Survivors of ACS, Chronic Angina, CHD related heart failure and) and Stroke • Aspirin/Clopidogrel • Anticoagulants • ACEI/ARIIB • Beta blockers (stroke: may not be indicated) • Statins • BP reduction • Smoking cessation • Rehabilitation

  12. CABG • Compared to Medical treatment: • Has an effect on mortality. • Benefit changes with: • Extent of coronary artery involvement • Ventricular function Yusuf et al. Lancet 1994; 344: 563-70.

  13. PCI • Compared to Medical treatment • It has no mortality benefit • It produces symptom relief. Bucher et al. BMJ 2000; 321: 73- 7.

  14. Drug eluting stents Boden et al. NEJM 356 (15): 1503

  15. Heart Failure • Progressive loss of the pump function of the heart • Definition: • Clinical syndrome + a measure of ventricular function. Some biomarkers are beeing increasingly used in clinical practice. • Therapy: • Decrease mortality from • Progressive heart failure • Sudden death • Symptom relief • Resource use control • Efficacy outcomes: • Rates of major cardiovascular events: • Death • Symptoms and Quality of Life • Proxy measures of ventricular function

  16. Available treatments for Heart Failure • Rehab • ACEI/ARII b • Aspirin? • Beta-blockers • Implantable Cardio Defibrillators • Spironolactone • Anticoagulants ? • Amiodarone? • Statins?

  17. Statins in Heart Failure • Current Debate: • Physiopathological thinking suggests a role • Role of statins in PostMI and CA • Observational evidence suggest an effect • Clinical trials: • CORONA : no effect • GISSI: expecting results

  18. Statins in heart failure CHD related Non CHD related J Am CollCardiol. 2008 Jan 29;51(4):415-26

  19. Key issues when modelling interventions • Mortality benefit or Quality of Life? • Which patients are eligible? • Current guidelines

  20. Key issues when modelling interventions • Efficacy vs effectiveness: • RCT and SR usually better than real practice • Uptake: those not receiving the drug do not benefit from it. • Many interventions acting on the same individuals: • Estimation of a common effect: The Mant-Hicks approach

  21. Summary • Patients groups • Strategies • High quality information on efficacy • AMI • PCI vs thrombolysis • Chronic Angina • CABG vs PCI vs Medical Management • Heart Failure • Statins • Key facts in modelling interventions

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