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L'ecocardiografia nell'ipertensione polmonare. L'ecocardiografia nel follw up

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l'ecocardiografia nell'ipertensione polmonare. l'ecocardiografia nel follow up

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L'ecocardiografia nell'ipertensione polmonare. L'ecocardiografia nel follw up

  1. 1. Laura ScelsiDivisione di CardiologiaFondazione IRCCS Policlinico San Matteo PaviaPavia, 27-28 marzo 2013L’ecocardiografia nell’ipertensione polmonareL’ecocardiografia nel follow up
  2. 2. The weighted mean reduction in RAP was – 1.84 mmHg (p<0.001)
  3. 3. The weighted mean reduction in CI was 0.18 L/min/mq (p<0.001)
  4. 4. The weighted mean reduction in PAPm was – 2.86 mmHg (p<0.001)
  5. 5. Circulation 2010;122:164-172
  6. 6. Circulation 2010;122:156-163
  7. 7. Long term intravenous epoprostenol infusion inPrimary Pulmonary HypertensionSitbon O, JACC 2002: 178 pts treated 92-0101020304050607080901000 1 2 3 4 5 6 yrEpoprostenolexpected survivalKaplan-Meier survival estimates in epoprostenol treated ptsand expected survival according to historical data33%63%
  8. 8. BUT
  9. 9. Per cui è necessario …UNA DIAGNOSI PRECOCE1) screening delle popolazioni a rischio2) sensibilizzazione della categoria medica
  10. 10. … ma non soloSTRATIFICAZIONE PROGNOSTICA1) In basale per iniziare un’adeguata terapia2) Nel follow up per verificare il raggiungimento degliobiettivi - goal oriented treatment strategy-È anche necessaria …3) Nel follow up per definire il timing per trapiantopolmonare/BSA
  11. 11. J Am Coll Cardiol 2002;40:780-8
  12. 12. Accredo Database: dati raccolti da un provider di farmaciin USA, relativi a 821 pz IP che iniziavano bosentan Mid-2006 characterized by shift in treatmentpatterns Accredo began focusing on combinationtherapy and evaluating therapy escalation Observation of disproportionately highnumber of patients dying on bosentanmonotherapy By mid-2007, this number had reached 89% ofall patients dying on bosentan or other oraltherapy This retrospective study determined survivalrates for patients initiated on bosentanmonotherapy and percentage of patients dyingon non-escalated therapy for a known cohortEscalated to prostacyclin therapy, 11%DeathsTankersley et al. Poster presented at: Pulmonary Hypertension Association’s 8thInternational PH Conference; June 20-22, 2008; Houston, TX.
  13. 13. Annals of Internal Medicine;1991:115Sopravvivenza media:WHO I-II 58,6 mesiWHO III 31,5 mesiWHO IV 6,0 mesi
  14. 14. Eur Respir Rev 2012;21:123,40-47
  15. 15. PERCENTSURVIVALTIME (yr)p=0.002PROGNOSIClinical difference between Idiopathic and Scleroderma-related Pulmonary Hypertension100%0%50%21 3 4Micah R. Fisher et al. Arthritis and Rheumatism 2006;54:3043-305097.4%88.6%48.2%82.5%IdiopaticScleroderma-related
  16. 16. Eur Respir Rev 2012;21:123,40-47
  17. 17. AJRCCM 2000 S. Miyamoto
  18. 18. Long-term epoprostenol infusion in primary pulmonary hypertension:Prognostic factors and survival. Sitbon O et al. JACC 2002;40:780-788
  19. 19. Eur Respir Rev 2012;21:123,40-47
  20. 20. P(t) = H(t)P(t) = H(t)A(PAPm, RAPm, CI)A(PAPm, RAPm, CI)SopravvivenzaRegistro NIH:1y1y2y2y3y3y68%68%57%57%48%48%H(t) = 0.88 - 0.14 t + 0.01 t2A(PAPm, RAPm, CI) = e(0.007325 PAPm + 0.0526 RAPm - 0.3275 CI)t = time in years5y5y 34%34%formula predittiva di sopravvivenza:D’Alonzo GE, Ann Intern Med 1991Equazione validata da:J Sandoval et al: Circulation 1994; 89:1733Registro NIHProspettico multicentrico32 Centri USA; 194 IPAH1981-1985Stratificazione prognosticaStratificazione prognostica
  21. 21. presente> 0.88< 15 mmdilatato> 1.7Eur Respir Rev 2012;21:123,40-47
  22. 22. Geometria del ventricolo destro(dilatazione/ipertrofia)Interazione ventricolo destro/sinistro(movimento del SIV)Funzione ventricolare destraAm J Cardiol 2012;110:16S-24S
  23. 23. ROC analysis: TAPSE <18mm predice SVI <29ml/m2 (CI < 2,2 l/min), masoprattutto predice la prognosi.PR Forfia, AJRCCM 2006Valutazione ecocardiograficaValutazione ecocardiograficadella funzione del ventricolo destrodella funzione del ventricolo destro
  24. 24. Valutazione eco della funzione del ventricolo destroValutazione eco della funzione del ventricolo destro59 IPAH pts; median f-up 52 months
  25. 25. Paziente A Paziente Bdonna, HIV+, anni 43 donna, IP idiopatica, anni 28
  26. 26. Paziente A Paziente B
  27. 27. Paziente A Paziente BClasse WHO III Classe WHO II6MWT: 470 mtFc 75 bpm; SO2 98%Fc 106 bpm; SO2 97%6MWT: 280 mtFc 90 bpm; SO2 95%Fc 118 bpm; SO2 92%BNP 890 pg/ml BNP 155 pg/ml
  28. 28. Paziente A Paziente BCateterismo cardiaco destroPAPm 40 mmHgPW 9 mmHgGTP 31 mmHgCI 2.01 l/min/m2PAD 13 mmHgPVR 11 UWCateterismo cardiaco destroPAPm 40 mmHgPW 10 mmHgGTP 30 mmHgCI 2.45 l/min/m2PAD 5 mmHgPVR 6 UW
  29. 29. Circulation 2000;102:865-870
  30. 30. Am J Respir Crit Care Med 1999;160:487-492
  31. 31. … come utilizzare questi parametriper definire la prognosi del paziente?
  32. 32. P(t) = H(t)P(t) = H(t)A(PAPm, RAPm, CI)A(PAPm, RAPm, CI)SopravvivenzaRegistro NIH:1y1y2y2y3y3y68%68%57%57%48%48%H(t) = 0.88 - 0.14 t + 0.01 t2A(PAPm, RAPm, CI) = e(0.007325 PAPm + 0.0526 RAPm - 0.3275 CI)t = time in years5y5y 34%34%formula predittiva di sopravvivenza:D’Alonzo GE, Ann Intern Med 1991Equazione validata da:J Sandoval et al: Circulation 1994; 89:1733Registro NIHProspettico multicentrico32 Centri USA; 194 IPAH1981-1985Stratificazione prognosticaStratificazione prognostica
  33. 33. Circulation 2010;122:164-172
  34. 34. Eur Respir Rev 2012;123:8–18
  35. 35. Chest 2012;141 (Issue 2)
  36. 36. The American Journal of Cardiology;2012;110:6S
  37. 37. … alla fine
  38. 38. Conclusioni• L’ipertensione arteriosa polmonare è una patologiaprogressiva a prognosi scadente per cui è necessarioun intervento precoce per migliorare la prognosi• La valutazione prognostica deve guidare il cliniconelle scelte terapeutiche e nella gestione del follow up• La stratificazione prognostica si basa sulla raccolta didiversi parametri clinici, funzionali, strumentali edemodinamici indicatori di disfunzione ventricolaredestra (valutazione multiparametrica)
  39. 39. Conclusioni• “a goal-oriented treatment strategy” rimanel’obiettivo principale del trattamento del paziente conipertensione arteriosa polmonare• Al momento, nonostante diversi tentativi, la strategia“goal-oriented” rimane molto dipendente all’equipeche gestisce il paziente, non permettendo cosìuniformità di trattamento

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