Transcript Document

EPIDEMIOLOGY
AND HISTORY
AHF
Disease Awareness
History of acute heart failure management
1900–1970
Early models of heart failure focussed on hemodynamics, with
edema as the key characteristic of the condition. This led to the
widespread use of diuretics in patients with heart failure1
Did you know?
Despite having being used for
decades, the effects of diuretics
on mortality and morbidity
have not been studied in
patients with heart failure7
The first half of the 20th Century saw the introduction of mercurial
diuretics for the treatment of congestive heart failure2,3
“... when heart failure occurs with normal rhythm, as in
hypertension, mercurial diuretics usually prove more successful
than digitalis in increasing the urinary output, in lessening
pulmonary congestion, and in relieving dyspnoea”4
The 1950’s saw the introduction of thiazide diuretics3 and
vasodilators such as hydralazine5
The loop diuretic furosemide was approved by the Food and Drug
Administration in 1966,6 while in 1967, the first human-to-human
heart transplant was performed.3 Both of these are still used today
in the management of heart failure7
1. Lechat et al. Eur Heart J Suppl 2006;8(Suppl C):C5–12; 2.Crawford et al. J Clin Invest 1925;1:333–58; 3. Davies et al.
BMJ 2000;320:39–42; 4. Evans et al. Br Heart J 1941:3:112–20;
5. Judson et al. Circulation 1956;13:664–74; 6. http://fdazilla.com/drugs (Accessed 1 May 2013); 7. McMurray et al. Eur
Heart J 2012;33:1787–847
Heart transplant image
History of acute heart failure management
1970–1990
The Framingham heart study was published in 1971 showing high
mortality in patients with heart failure:1
“Despite modern management, congestive heart failure proved to
be extremely lethal. The probability of dying within five years from
onset of congestive heart failure was 62% for men and 42% for
women”
Did you know?
Acute heart failure is still
associated with high levels of
mortality; 30-day, 1-year and
5-year mortality rates for
patients hospitalized for acute
heart failure are approximately
10%, 22% and 42%,
respectively*4
During the 1970’s and 1980’s, inotropes and intravenous nitrates
were approved for patients with acute heart failure.2 These were
the first advances in therapy in over a decade – there have been
relatively few advances since
Although nitrates are still used in the management of acute heart
failure today, there is no robust evidence that they relieve
dyspnoea or improve other clinical outcomes
*A population-based study assessed survival rates for patients hospitalized for heart failure between 1987–2002 from four
communities within the USA
1. McKee et al N Engl J Med 1971;285:1441–6; 2. http://fdazilla.com/drugs (Accessed 1 May 2013); 3. McMurray et al. Eur
Heart J 2012;33:1787–847; 4. Loehr et al. Am J Cardiol 2008;101:1016–22
Intravenous drip
History of acute heart failure management
2000–Present day
Launch of two new agents for acute heart failure, but they are not
approved by regulatory authorities in all markets: B-type natriuretic
peptide (nesiritide; 2001; US only1); calcium sensitizer (levosimendan;
2000; Scandinavia, Russia, Latin America2)
A number of novel therapies fail to demonstrate outcome
benefits in clinical trials in patients with acute heart failure:3–6
Clinical trials with a vasopressin V2 receptor blocker , an endothelin
receptor antagonist and an adenosine receptor fail to demonstrate
improvements in long-term ouctomes3–5
Did you know?
The main therapies for acute
heart failure recommended by
the guidelines (loop diuretics,
vasodilators and inotropes) are
the same therapies that have
been used for decades11,12
There remains a significant
need for improved disease
management and new
treatment options that reduce
mortality in patients with acute
heart failure
2011: Several years after launch, a pivotal study shows artificial B-type
natriuretic peptide has no effect on outcomes in patients with acute heart
failure6
Hope on the horizon? The need to raise awareness of acute heart failure
and improve patient care pathways is being increasingly recognized and
many medical associations and have initiatives to address this.7–9
Meanwhile, a number of potential novel therapies for acute heart failure
are currently in clinical development10
1. http://fdazilla.com/drugs/application/020920 (Accessed 1 May 2013);
2. http://www.orion.fi/Documents/Publications%20and%20Media%20main%20file/Presentation%20materials%20PDF/
Simdax%20Fact%20Sheet.pdf (Accessed 1 May 2013); 3. Konstam et al. JAMA 2007;297:1319–31; 4. McMurray et al. JAMA 2007;298:2009–19; 5. Massie et al. N Engl J Med
2010;363:1419–28; 6. O’Connor et al. N Engl J Med 2011;365:32–43; 7. Cowie et al. Br J Cardiol 2013;20(suppl 2):S1–S11; 8. European Society of Cardiology Heart Failure Awareness
Day http://www.escardio.org/communities/HFA/heart-failure-awareness-day-2013/Pages/european-heart-failure-awareness-day-2013.aspx (Accessed 29 April 2013); 9. British Heart
Foundation ‘Mending Broken Hearts’ Appeal http://www.bhf.org.uk/mending-broken-hearts-appeal.aspx#&panel1-1 (Accessed 29 April 2013); 10. Ezekowitz. Curr Cardiol Rep
2013;15:329; 11. McMurray et al. Eur Heart J 2012;33:1787–847; 12. Ramirez & Abelmann. N Engl J Med 1974;290:499–501
Lack of awareness:
Acute coronary syndromes and acute heart failure: similar
burden but different levels of understanding and progress
Incidence:
Incidence: 1 million/year
Incidence: 1 million/year
Mortality:
Pre-hospital mortality: high
In-hospital mortality: 3–4%
60–90 day mortality: 2%
Pre-hospital mortality:
unknown
In-hospital mortality: 3–4%
60–90 day mortality: 10%
Targets of therapy:
ACS
Targets of therapy: thrombosis
Targets of therapy: unclear
Clinical trial results:
Clinical trial results:
numerous; beneficial
Clinical trial results:
minimal; no mortality
benefits
Current standard of therapy:
Antiplatelets; anticoagulants
Diuretics and vasodilators
Evidence level for current standard of therapy:
Numerous, large RCTs
ESC: level A
Few, small RCTs
ESC: level B–C
ACS=acute coronary syndrome; AHF=acute heart failure; ESC=European Society of Cardiology; RCTs=randomized controlled trials
Adapted from Weintraub et al. Circulation 2010; 122:1975–96; McMurray et al. Eur Heart J 2012;33:1787–847; Hamm et al. Eur Heart J 2011;32:2999–3054
AHF
Resource and economic burden:
Heart failure imposes a significant economic burden on the
healthcare system
IN THE USA ALONE, THE ESTIMATED
ECONOMIC BURDEN OF HF FOR 2013 IS
$ $ $ $ $ $ $ $ $ $
$ $ $ $ $ $ $ $ $ $
$ $ $ $ $ $ $ $ $ $
$ $ $ $ $ $ $ $ $ $
$ $ $ $ $ $ $ $ $ $
US$ 32 billion
‡1
70%
OF THE COST OF HF IS
DUE TO HOSPITALIZATIONS2
10%
OF THE COST OF HF IS
DUE TO PHARMACOLOGICAL
TREATMENT3
~
THE TOTAL COST OF HF IN THE USA
ALONE IS EXPECTED TO INCREASE
More than
2% of the total
healthcare
budget
in many countries is
spent on the
treatment of HF2
‡1
~120% by 2030
HF=heart failure; ‡Estimate includes direct costs (total annual medical spending) and indirect costs (lost productivity due to morbidity and mortality)
1. Go et al. Circulation 2013;127:e6–e245; 2. Dickstein et al. Eur Heart J 2008;29:2388–442; 3. Hunt et al. J Am Coll Cardiol 2009;53:e1–90
An introduction to the burden of heart failure :
Heart failure is a major and growing
public health problem
PREVALENCE1
INCIDENCE2–4
GROWTH5
(new cases per 100,000 per
year)
~2%
~2%
HF
~15 m
Increasing
prevalence of
risk factors5,6
of the population in
Europe have HF1
As many as 1 in 5
people aged 70–80
years have HF1
219
130
PREVALENCE
Improved
post-MI
survival5
70‡
An aging
population5
HF=heart failure; MI=myocardial infarction; ‡Calculated using the incidence rate of HF in 1997 for Hong Kong and applying it to the Chinese population
1. Dickstein et al. Eur Heart J 2008;29:2388–442; 2. Go et al. Circulation 2013;127:e6–e245; 3. Allender et al. Coronary Heart Disease Statistics 2008;
4. Hung et al. Hong Kong Med J 2000;6:159–62; 5. Hunt et al. J Am Coll Cardiol 2009;53:e1–90; 6. Kearney et al. Lancet 2005; 365:217–23
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