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Novedades en fisiopatología y diagnóstico de la IC

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Ponencia presentada por el Dr. José Manuel García Pinilla en el directo online ‘Highlights del congreso HFA 2018: una mirada a Europa’, realizado el 15 de junio de 2018 en la XV Reunión Anual de la Sección de Insuficiencia Cardiaca de la SEC en Toledo.

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Novedades en fisiopatología y diagnóstico de la IC

  1. 1. NOVEDADES EN FISIOPATOLOGÍA Y DIAGNÓSTICO DE LA INSUFICIENCIA CARDIACA José Manuel García Pinilla Hospital Universitario Virgen de la Victoria (Málaga)
  2. 2. Incidencia de la insuficiencia cardiaca en USA Fig. Temporal trends in heart failure. (a) Burden of heart failure. The actual annual incidence of heart failure reported in the United States (squares and dotted line) exceeded the projected annual incidence (triangles and solid line) calculated based on a stable incidence of 10 per 1000 person-years in persons aged 65 years and older. (b) Temporal trends in HFpEF. The solid lines represent the regression lines for the relation between the year of admission and the percentage of patients with heart failure. The dashed lines indicate 95% confidence intervals. (c) Temporal trends in HFpEF and HFrEF. The solid lines represent the regression lines for the relation between the year of admission and the percentage of patients with heart failure. The dashed lines indicate 95% confidence intervals. Lund & Saverese. ESC Textbook 2018 (in press).
  3. 3. Conrad N, et al. Lancet. 2018 Feb 10; 391(10120): 572-580.
  4. 4. Conrad N, et al. Lancet. 2018 Feb 10; 391(10120): 572-580.
  5. 5. Conrad N, et al. Lancet. 2018 Feb 10; 391(10120): 572-580.
  6. 6. Increased all-cause mortality in newly diagnosed patients with heart failure between 2006 and 2012 • Retrospective, population-based study in Sweden (from 2006 to 2012). Newly diagnosed patients with HF, N= 141,607 • Mean age, distribution of men and women, and proportion of patients first diagnosed in an inpatient setting remained constant • Mean (standard deviation [SD]) Charlson Comorbidity Index increased from 1.4 (1.8) to 1.7 (2.2) (p <0.0001) • Proportion of patients with a previous myocardial infarction decreased significantly from 14% to 12% (p <0.0001) Lindmark K. Increased all-cause mortality in newly diagnosed patients with heart failure between 2006 and 2012: a retrospective, population-based study in Sweden. Eur J Heart Fail. 2018 May; 20 Suppl 1: 5-638.
  7. 7. Diagnóstico «Nuevas» tecnologías Biomarcadores Técnicas de imagen
  8. 8. Diagnóstico «Nuevas» tecnologías Biomarcadores Técnicas de imagen
  9. 9. Técnicas de imagen • Ecocardiograma • RMN y PET • Tomografía computarizada • Imagen híbrida • Imagen molecular
  10. 10. Técnicas de imagen • Ecocardiograma • RMN y PET • Tomografía computarizada • Imagen híbrida • Imagen molecular
  11. 11. Pinto FJ. Echocardiography - Novel techniques and tricks. Heart Failure 2018 (Vienna).
  12. 12. • Rápido • Preciso • Reproducible • Buena correlación con 3D manual (r= 0,87-0,96) • Buena correlación con RMN (r= 0,84-0,95) Pinto FJ. Echocardiography - Novel techniques and tricks. Heart Failure 2018 (Vienna).
  13. 13. Pinto FJ. Echocardiography - Novel techniques and tricks. Heart Failure 2018 (Vienna).
  14. 14. Pinto FJ. Echocardiography - Novel techniques and tricks. Heart Failure 2018 (Vienna). Fig. Measurements of the ventricular volumes, ejection fraction and deformation parameter area strain, using three-dimensional speackle-tracking echocardiography. De: Altman M et al. Ear Heart J Cardiovasc Imaging 2014;15:316-323
  15. 15. Platz E. Novel imaging and monitoring devices. Lung ultrasound. Heart Failure 2018 (Vienna).
  16. 16. Platz E. Novel imaging and monitoring devices. Lung ultrasound. Heart Failure 2018 (Vienna).
  17. 17. Lung ultrasound may reduce heart failure hospitalizations: preliminary results from the LUS-HF trial Mercedes Rivas-Lasarte on behalf of the LUS-HF investigators Hospital de la Santa Creu i Sant Pau, Cardiology Department, Barcelona, Spain
  18. 18. Stankovic I. Novel imaging and monitoring devices. FoCUS. Heart Failure 2018 (Vienna).
  19. 19. Técnicas de imagen • Ecocardiograma • RMN • Tomografía computarizada • Imagen híbrida • Imagen molecular
  20. 20. ESC Heart Failure Guidelines - Cardiovascular MRI • Gold standard for the assessment of volumes, mass and EF  High accuracy and reproducibility • Preferred imaging method to assess myocardial fibrosis using: • Late gadolonium enhancement (LGE) – focal fibrosis • T1 Mapping- diffuse intersticial fibrosis Ponikowski et al. EHJ 2016.
  21. 21. Manka R. Cardiac magnetic resonance imaging and positron emission tomography. Heart Failure 2018 (Vienna).
  22. 22. Técnicas de imagen • Ecocardiograma • RMN • Tomografía computarizada • Imagen híbrida • Imagen molecular
  23. 23. Achenbach S. The value of cardiac CT in heart failure. Heart Failure 2018 (Vienna).
  24. 24. Achenbach S. The value of cardiac CT in heart failure. Heart Failure 2018 (Vienna).
  25. 25. Achenbach S. The value of cardiac CT in heart failure. Heart Failure 2018 (Vienna).
  26. 26. Técnicas de imagen • Ecocardiograma • RMN • Tomografía computarizada • Imagen híbrida • Imagen molecular
  27. 27. Why hybrid imaging? Celukienè J. Hybrid imaging: it takes two to tango. Heart Failure 2018 (Vienna).
  28. 28. Juneau. Circ Cardiovasc Imaging 2017.
  29. 29. PET/MRI position statement. Eur Radiol 2017. Ischemic cardiomyopathy: blood flow and viability parameters in one session combined with late gadolinium enhancement PET tracer of myocardial innervation could be added to the imaging protocol Hybrid 18-FDG PET/MRI to diagnose active cardiac sarcoidosis Dweck & Abgral. JACC Cardiovasc Imaging 2017.
  30. 30. Diagnóstico «Nuevas» tecnologías Biomarcadores Técnicas de imagen
  31. 31. Established biomarkers: who is hot and who is not? Richards. Interpretation of biomarkers in CHF – Easier said than done. Established Biomarkers – Who´s hot and who´s not. Heart Failure 2018 (Vienna).
  32. 32. Brunner-La Rocca. Interpretation of biomarkers in CHF – Easier said than done. Natriuretic peptides. Heart Failure 2018 (Vienna). Richards. Interpretation of biomarkers in CHF – Easier said than done. Established biomarkers – Who´s hot and who´s not. Heart Failure 2018 (Vienna).
  33. 33. Meta-analysis of (NT-pro)BNP guided therapy (mortality): HFrEF vs HFpEF Brunner-La Rocca et al. Eur J Heart Fail. 2015; 17: 1252. Meta-analysis of 8 trials.
  34. 34. Brunner-La Rocca. Interpretation of biomarkers in CHF – Easier said than done. Natriuretic peptides. Heart Failure 2018 (Vienna).
  35. 35. 2017 ACC/AHA/HFSA Focused Update • New data suggests that natriuretic peptide biomarker screening and early intervention may prevent HF Yanci et al. Circulation 2017. Lam CSP. Role of biomarkers in CVD intensive preventive therapy among T2DM – Current guidelines and future perspectives. Heart Failure 2018 (Vienna).
  36. 36. • 1374 participants with CVRFs from 39 primary care practices in Ireland • Randomized to: 1. Usual primary care (control condition; n= 677) versus 2. Screening with BNP testing (n= 697) • Intervention-group with BNP ≥50 pg/mL underwent echo and collaborative care between primary care and specialist CV service • Primary end point: prevalence of asymptomatic LV dysfunction with or without newly diagnosed HF Lam CSP. Role of biomarkers in CVD intensive preventive therapy among T2DM – Current guidelines and future perspectives. Heart Failure 2018 (Vienna).
  37. 37. • 300 patients with T2DM and NT-proBNP >125 pg/mL but free of cardiac disease • Randomized to “control” group (cared for at 4 DM care units); vs “intensified” group (additionally treated at a cardiac outpatient clinic for the up-titration of RAS antagonist and beta-blockers) • Primary endpoint was hosp/death due to cardiac disease after 2 years Lam CSP. Role of biomarkers in CVD intensive preventive therapy among T2DM – Current guidelines and future perspectives. Heart Failure 2018 (Vienna).
  38. 38. New biomarkers Di Somma S. Interpretation of biomarkers in CHF – Easier said than done. New Biomarkers. Heart Failure 2018 (Vienna).
  39. 39. Troponin related in-hospital mortality in AHF patients Di Somma S. Interpretation of biomarkers in CHF – Easier said than done. New biomarkers. Heart Failure 2018 (Vienna).
  40. 40. Bio-ADM and congestion in heart failure Di Somma S. Interpretation of biomarkers in CHF – Easier said than done. New biomarkers. Heart Failure 2018 (Vienna).
  41. 41. Proenkephalin (penKid) is the strongest predictor of WRF in acute heart failure patients GREAT AHF Study N= 1908 • Multicentric, observational study in patients with AHF presenting to the ED of participating university hospitals in 3 countries • 264 patients developed WRF (rise in plasma creatinine of >26.5) mmol/L or 50% higher than the admission value) Di Somma S. Interpretation of biomarkers in CHF – Easier said than done. New biomarkers. Heart Failure 2018 (Vienna). Mebazaa. Biomarkers – Tips and tricks. Renal biomarkers. Heart Failure 2018 (Vienna).
  42. 42. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure Tousoulis. Biomarkers – Tips and tricks. Inflammatory biomarkers. Heart Failure 2018 (Vienna).
  43. 43. One marker good… Many markers better? Cumulative hazard curves demonstrating the ability of a multimarker strategy using CRP, ST2, BUN, hemoglobin, and NT-proBNP to predict hazard both early and in a sustained fashion BUN = blood urea nitrogen Richards. Interpretation of biomarkers in CHF – Easier said than done. Established Biomarkers – Who´s hot and who´s not. Heart Failure 2018 (Vienna).
  44. 44. Diagnóstico «Nuevas» tecnologías Biomarcadores Técnicas de imagen
  45. 45. CardioMEMS HF System for the management of chronic heart failure Abraham WT, et al. Lancet 2011. Rosenkranz. Beat as One: united in the fight against heart failure - Improving clinical outcomes and enhancing life; Wireless pulmonary artery pressure monitoring in HFpEF: guidance to effectively reduce decompensation. Heart Failure 2018 (Vienna). Abraham. Novel imaging and monitoring devices. CardioMEMS. Heart Failure 2018 (Vienna).
  46. 46. Microelectrical Mechanical System (MEMS) No lead or battery, no need for replacement Rosenkranz. Beat as One: united in the fight against heart failure - Improving clinical outcomes and enhancing life; Wireless pulmonary artery pressure monitoring in HFpEF: guidance to effectively reduce decompensation. Heart Failure 2018 (Vienna). Abraham. Novel imaging and monitoring devices. CardioMEMS. Heart Failure 2018 (Vienna).
  47. 47. Desai AS, et al. J Am Coll Cardiol 2017. Rosenkranz. Beat as One: united in the fight against heart failure - Improving clinical outcomes and enhancing life; Wireless pulmonary artery pressure monitoring in HFpEF: guidance to effectively reduce decompensation. Heart Failure 2018 (Vienna). Abraham. Novel imaging and monitoring devices. CardioMEMS. Heart Failure 2018 (Vienna).
  48. 48. Features of mobile phones relevant to HF-management • App to differentiate between patients with AF and sinus rhythm • Using the camera of iPhone 4S • 80 Patients (AF/SR: 50%/50%) • Sensitivity 87.5% Köhler. Novel imaging and monitoring devices. Mobile phone applications. Heart Failure 2018 (Vienna).
  49. 49. CONCLUSIONES • UN PROBLEMA EPIDEMIOLOGICO “FUERA DE CONTROL” • TECNOLOGÍA CRECIENTE EN DIAGNÓSTICO (IMAGEN HÍBRIDA) PERO PAPEL MUY RELEVANTE DEL ECO PULMONAR • NUEVOS BIOMARCADORES. GAPS EN LA TERAPIA GUIADA • ¿LA TECNOLOGÍA NOS DESBORDARÁ O NOS AYUDARÁ?
  50. 50. Cibeles fountain (Madrid) City Hall (Cáceres) La Farola (Málaga) City Hall (Granada) Cabildo Insular (Tenerife) Hejduk Towers (Santiago) Marbella’s Arch (Marbella) Virgen de la Macarena’s Hospital (Sevilla) Lighting of 18 buildings (2/2) José Antonio Labordeta’s park (Zaragoza) Plaza de España’s fountain (Sevilla) City Hall (Santiago) Don Juan de Austia’s roundabout (Sevilla) Campoamor’s theatre (Oviedo) Hercules’ tower (A Coruña) City Hall (Gijón) Santa Catalina’s castle (Jaén) Lighthouse (Sitges) Media coverage (2/3) • Some examples of news articles published for the HF Awareness Day: Health educational activities (4/4) ove by heart physicians: the HF”. CHUAC hospital. hop by celebrity y around the k. MUCHAS GRACIAS

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