Richard Horton , Lancet 2005

1. Richard Horton , Lancet 2005

2. Malattia Cronica : tempo….. “A disease that persists for a long time. A chronic disease is one lasting 3 months or more, by the definition of the U.S. National Center for Health Statistics. “A disease lasting indefinitely. “ “An illness marked by long duration or frequent recurrence” Malattia Cronica : prognosi…. “Chronic diseases generally cannot be preventedby vaccines or cured by medication, nor do they just disappear “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”

3. Determinanti socioeconomici culturali ,politici, ambientali Fattori di rischio intermedi Fattori di rischio comuni , modificabili Dieta incongrua Sedentarietà Uso di tabacco Ipertensione Ipotolleranza glucidica Obesità Dislipidemia Globalizzazione Urbanizzazione Invecchiamento della popolazione Fattori di rischio non modificabili Età Ereditarietà Cause delle malattie croniche MALATTIA CRONICA Mal CV Diabete BPCO Neoplasia

4. Preventing chronic diseases: a vital investment — WHO global report. Geneva: World Health Organization, 2005.

5. Preventing chronic diseases: a vital investment — WHO global report. Geneva: World Health Organization, 2005.

6. Did you know?? Chronic diseases • Cardiovascular disease, mainly heart disease, stroke • Cancer • Chronic respiratory diseases • Diabetes 35 000 000 Strong et al, Lancet 2005

7. 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

8. Booth GL Lancet 2006; 368: 29–36 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. Diabetes confers an equivalent risk to ageing 15 years

9. Prevalence of Diabetes* P=0.004 * Self-reported history of diagnosed diabetes S2 vs. S1 : P=0.21 S3 vs. S2 : P=0.02 S3 vs. S1 : P=0.001 Euro Heart Survey Programme 2007ESC Quality Assurance Programme to Improve Cardiac Care in Europe

10. Risks are increasing

11. Prevalence of Obesity* P=0.0006 S2 vs. S1 : P=0.009 S3 vs. S2 : P=0.051 S3 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

13. Estimated prevalence of GOLD stage 2 or higher COPD Mannino DM :Lancet 2007; 370: 765–73

14. TheARIC Study:Mannino DM:Respir Med 2006; 100: 115

15. Funzione Normali oscillazioni stato clinico Riacutizzazioni ? CHEST 2000; 117:398S tempo Peggioramento acuto, inatteso, sostenuto… Respiratori • dispnea(respiro corto, rapido) • tosse • espettorato  purulento Segni e sintomi Sistemici • temperatura • frequenza cardiaca  stato mentale Cosa e’una riacutizzazione di BPCO dal punto di vista clinico?

16. 38-55%,  266 - 385 milioni 27%, 130 milioni 28%, 50 milioni prevalenza di ipertensione arteriosa nel mondo: un’ epidemia incombente 1 miliardo di ipertesi USA & Canada Europa Cina Wolf-Maier K et al. Hypertension 2004 JNC 7 2003 Dongfeng G et al Hypertension 2002

17. Pressione e mortalità ictus Ischemia cardiaca sistolica diastolica

19. IV=(P≥65/P≤14)*100 242.0

20. (da Pulignano G, 2005)

21. Sempre più su……….

22. Number of Cardiovascular Deaths Projected to 2020 Millions

23. Si può fare qualcosa?

24. 160 DIABETICI TIPO 2 FOLLOW UP 7.8 ANNI ETA’ MEDIA 55 A. TUTTI MICROALBUMINURICI Terapia intensiva su tutti i fattori di rischio - 20% Morte + eventi cardiovascolari Gaede P. NEJM 2003;348:383

25. Benefici della terapia antipertensiva dimostrati nei trials con PA clinica(riduzione di circa 10 sist./5 dia. mmHg) –35-40% -20-25% -50% Riduzione % del rischio relativo rallentamento progressione IR

26. RR=0.64

27. BMJ published online 11 Oct 2007; 12 studi , 8307 pazienti

28. Home Based Intervention • 297 pts per 4.2 anni • età media 75 anni • 50% ischemici • 30% diabetici + 28% Stewart S Circulation 2002;105:2861

29. Authors’ conclusions Exercise 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

30. BMJ 2006;332:1379

31. A U T H O R S ’ C O N C L U S I O N S “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.”

32. 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

33. BMJ 2004;329:1209–11

34. “ Ma è davvero così semplice?”

35. Compliance Adherence

36. Nella cronicità il paziente deve assumere e condividere la responsabilità della terapia e della sua salute La formazione del paziente ad un’autogestione consapevole della malattia diventa parte integrante della terapia La terapia nella malattia cronica

37. Adesione e malattie croniche • Nonostante la ricerca clinica abbia raggiunto risultati rilevanti • per il trattamento e per il controllo delle patologie croniche, • più del 50% dei pazienti cronici • non riesce ad eseguire correttamente la terapia consigliata

41. Che fa il buon dottore? • Good doctors use • both • individual clinical expertise • and • the best available evidence, • and • neither is enough Sackett DL et al, BMJ 1996; 312: 71-2

42. E’ necessario l’intervento del paziente

44. Dying slowly, painfully and prematurely

45. Causes of chronic diseases

46. The economic impact: billions

47. Si può fare qualcosa su base mondiale?

48. The 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.

50. Epping-Jordan et al, Lancet 2005