Enfermedad Cardiovascular, Neumonía y Complicaciones

Prof. Francesco Blasi

Department of Pathophysiology and TransplantationUniversity of Milan, Italy

Disclosures

• I have accepted grants, speaking and conference invitations from AstraZeneca, Almirall, Bayer, GSK, Novartis, Pfizer, Chiesi, Guidotti-Malesci, Menarini and Zambon

• I have had recent or ongoing consultancy with AstraZeneca, GSK, Mundipharma,Novartis, Almirall, Menarini

18–34 Years 35–49 Years 50–64 Years ≥65 Years0

100

200

300

400

500

600

700

11 17 2567

28 37 54

138101 85

127

286332

216

326

618

109 101149

290

Healthy

At-Risk 1 Condition

At-Risk 2 Conditions

At-Risk 3 Conditions

High Risk

Inci

denc

e/10

0,00

0

Age

Multiple Comorbidities Further Increase Pneumococcal Pneumonia Risk in Adults

Estimated Annual Incidence of Pneumococcal Pneumonia in the United States in Adults, by Number of Comorbidities

Persons with ≥2 at-risk conditions accounted for 9%–32% of all at-risk adults, depending on age

4

Pelton SI, et al. Presented at ISPPD 2014, Hyderabad, India. OP-390.

Pneumonia and Cardiovascular events PATHOPHYSIOLOGICAL MECHANISMS

Corrales-Medina. Lancet 2012

Identification and prevention of cardiovascular events in pneumonia

T0 T1 T3 T4 T5 T6T2 T7

+

-

CAP

Non-resolving pneumonia

Improvement

Failure

ERDuring hospitalization After discharge

Rehospitalized

ER

C

C

C

C

Cardiovascular events and pneumonia

Ramirez J. CID 2008; 47:182–7

T0 T1 T3 T4 T5 T6T2 T7

+

-

CAP

ER

On Hospital admission: AMI

During the hospital course: Failure and AMI

T0 T1 T3 T4 T5 T6T2 T7

+

-

CAP

Non-resolving pneumonia

Failure

ER During hospitalization

Aliberti S. Chest 2008; 134:955–962

During the hospital course: Improvement and AMI

T0 T1 T3 T4 T5 T6T2 T7

+

-

CAP

Clinical stability

Improvement

ER During hospitalization

Ramirez J. CID 2008; 47:182–7

The concurrence of pneumonia and a new cardiac event was often unrecognized, especially in the first 12–24 h of hospitalization, resulting in some patients not receiving

cardiac monitoring or anticoagulant therapy.

Musher DM. CID 2007; 45:158–65

Pneumococcal CAP & Cardiac events

Jasti H. CID 2008; 46:550–6

T0 T1 T3 T4 T5 T6T2 T7

+

-

CAP

Non-resolving pneumonia

Improvement

Failure

ERDuring hospitalization After discharge

Rehospitalized

After Hospital discharge: cardiovascular events

Reason of Rehospitalization

Reference Year n. Pts Design CVE Heart Failure

Arrhytmias AMI

Muscher 2007 170 In-pts VA RetroSingle

19% 15% 6% 7%

Becker 2007 391 In-pts Retromulti

17% 12% 3% 8%

Ramirez 2008 500 In-pts VA RetroSingle

-- -- -- 6%

Corrales-Medina

2009 206 In-pts VA RetroSingle

-- -- -- 11%

Perry 2011 50,119 In-pts VA RetroMulti ICD

-- 9% 8% 1%

Mandal 2011 4,408 In-pts RetroMulti ICD

-- -- 9% 3%

Corrales-Medina

2012 2,287 In-ptsOut pts

RetroMulti

(PORT)

27%2%

18%1%

6%1%

1%0

Griffin 2013 3,068 In-pts RetroMultiCAPO

12% 4% 8% 2%

Pneumonia and Cardiovascular events State of the Art

Corrales-Medina VF. Circulation 2012

1343 inpatients and 944 outpatients CAPThe 30-day mortalityCAP: 2.8%CAP + CVE: 15%

Pneumonia and Cardiovascular events IMPACT on MORTALITY

Viasus D. Journal of Infection (2013) 66, 27e33

Pneumonia and Cardiovascular events RISK FACTORS for CVE

Variable Griffin 2013

Viasus 2013

Corrales-Medina 2012

Age -- 1.78 1.03

Nursing Home 1.8

Hyperlipidemia 2.01

Cardiac Arrhytmias 1.8

CAD 1.5

Hypertension 1.5

CHD/CHF 3.05 4.3

Hypoalbuminemia 2.3

Statins 0.52

PSI 1.02

Septic Shock 1.7

Tachycardia 1.6

RR>30 1.6

Multilobar 1.36

S. aureu 1.61

K. pneumoniae 2.95

S. pneumoniae 1.39

Demographics

Comorbidities

Severity on admission

Pathogen

From epidemiology to intervention

From epidemiology to intervention

300mg of aspirin daily for

1 month.

From epidemiology to intervention

From epidemiology to intervention

Protective effect of statins against the development of CAP

From epidemiology to intervention

Protective effect of statins against the development of CAP

Statin use was significantly associated with reduced mortality in patients

with CAP.

From epidemiology to intervention

Protective effect of statins against the development of CAP

Statin use was significantly associated with reduced mortality in patients

with CAP.Low quality evidence

From epidemiology to intervention

KEY POINTS-CVEs in CAP patients could be mediated by plaque related mechanisms (leading to acute myocardial infarction) versus plaque-unrelated mechanisms (leading to arrhythmias and heart failure).-The prevalence of CVEs in CAP varies broadly from 10 to 30%, with a substantial impact of both short and long-term outcomes.

• Clinical tools that stratify CAP patients according to their risk to develop cardiac complications may be useful for both clinical and research purposes

• Interventions to prevent the development and progression of cardiac complications in high-risk patients with pneumonia and characterise the effect of these strategies on pneumonia-associated morbidity, mortality, health-care utilisation, and costs

KEY POINTS

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