Heart failure has been likened to a global epidemic North America Europe Canada USA France UK 1.5% 1.9% ~1–2% 2.2% 1.3% Asia China Japan Malaysia Singapore 1.3% ~1% 6.7% 4.5% CẬP NHẬT SUY TIM 2019 Australasia Australia Latin America No population-based estimates PGS TS Châu Ngọc Hoa Đại học Y Dược Tp Hồ Chí Minh Africa No population-based estimates Middle East Oman 0.5% Ponikowski P, et al 2014 WHFA White Paper European Society of Cardiology nguyên nhân suy tim hàng đầu CAD BN CAD vượt qua van tim đừng háng đầu, bên cành THA mục tiêu điều trị ban đầu giảm tử vong cho BN Most Common Causes of Heart Failure Around the World 1.3% mục tiêu nghiên cứu giảm tỉ lệ tử vong nhập viện suy tim tỉ lệ tử vong năm 8.1 1/3 nhập viện năm cut off 40% sau mốc tỉ lệ tử vong tăng vọt Survival curves in pts with EF > 40% vs EF < 40% 100 Mortality at year 8.1% Hosp at year 28% 80 học Limitations Cardiology setting No echo monitoring Diagnosis no centrally validated p40 % (53) EF < 30 % (447) EF < 25 % (404) 20 Stevenson LW et al Circulation 1995; 92: 174-181 EF < 20 % (250) EF < 15 % (123) Chioncel O et al for the ESC-HF-LT registry EJHF 2017; 19:1574-85 12 15 18 21 24 Months after evaluation chẩn đốn ST bắt buộc phải có triệu chứng dấu hiệu sau dựa EF để phân loại chẩn đốn phải có yếu tố: dấu hiệu triệu chứng + siêu âm tim + BNP thiếu chủng ngừa cúm thiếu ARNI What is new in the therapeutic algorithm ? Definition of heart failure with preserved (HFpEF), mid-range (HFmrEF) and reduced ejection fraction (HFrEF) HF Management Overview Lifestyle Changes/ Patient Education1 • • • • • • • • Identifying HFmrEF as a separate group will stimulate research into underlying characteristics, pathophysiology and treatment of this population Weightloss Smoking cessation Low-sodium diet Exercise training Cardiac rehab Medication adherence Symptom monitoring Self-care Guideline-Directed HF Therapies1-4 • • • • • • • RAAS blockade β-blockers Aldosterone antagonists Funny channel inhibition HYD/ISDN Diuretics Digoxin Devices1 • • • CRT ICD Ventricular assist devices Transplantation in Advanced HF1 • • Gold standard for the treatment of refractory endstage HF 1-year posttransplant survival rate of 88% Palliative Care1 • • • • • Access to treatment and endof-life care Control of symptoms, psychological distress, and HRQOL Advance directives Caregiver support Frailty/dementia assessments CRT, cardiac resynchronization therapy; HYD/ISDN, hydralazine/isosorbide dinitrate; ICD, implantable cardioverter-defibrillator; RAAS, renin-angiotensin aldosterone system Yancy CW et al Circulation 2013;128(16):e240-e327 Yancy CW et al Circulation 2016;134(13):e282-e293 Kim Y et al Ifunny channel inhibitors: an emerging option for heart failure In: CADTH Issues in Emerging Health Technologies 2017 Yancy CW et al Circulation 2017;136(6):e137-e161 Heart Failure with Reduced EF Tried and True New and Improved – Ace Inhibitors/Angiotensin – Receptor Blockers – Beta Blockers – – Aldosterone Receptor Blockers – Hydralazineand Nitrates có CCĐ SacubitrilValsartan (PARADIGM-HF, PIONEERHF) Ivabradine(SHIFT, SHIFT-HF) có giảm tử Yancy, et al HF Guidelines Circ 2013; 128: 240-327 10 dùng liều tối ưu RAS BB 11 12 HFrEF ARNIs Symptoms Optimal Rx ACEi or ARB 13 15 14 Initial Dose Target Dose 100 200 16 Lor trị THA liều 100mg HF 150mg 2016 ESC HF Guidelines 17 18 không dung napj UCMC ARB có chống định ta sử dụng hydralazin ISDNT để giảm tử vong cịn triệu chứng nhịp xoang ln xem xét digoxin để giảm nhập viện liều thấp, viên 0,25mg sử dụng nửa viên viên nguy ngộ độc thấp sử dụng nửa viên: già, phổi mạn, tăng Ca, giảm K nhịp xoang, nhịp nhanh rung nhĩ đáp ứng thất nhanh HFr CCĐ: nhịp chậm, block av cao độ, RL nhịp thất, WPW, tim phì đại có tắc nghẽn ? ? 19 20 Slide Draft Presentation March 8, 2019 Heart Failure with Reduced EF Tried and True New and Improved – Ace Inhibitors/Angiotensin Receptor Blockers – Beta Blockers – Aldosterone Receptor Blockers – Hydralazineand Nitrates – SacubitrilValsartan (PARADIGM-HF, PIONEERHF) – Ivabradine(SHIFT, SHIFT-HF) Initiation of Angiotensin-Neprilysin Inhibition after Acute Decompensated Heart Failure: Results of the Open-Label Extension of the PIONEER-HF Trial Adam D DeVore1, Eugene Braunwald,2 David A Morrow,2 Carol I Duffy,3 Andrew P Ambrosy,4 Kevin McCague,3 Ricardo Rocha,3 Eric J Velazquez5 1Duke Univ/Duke Clinical Res Inst, Durham, NC; 2Harvard Univ/Brigham and Women's Hosp, Boston, MA; 3Novartis Pharmaceuticals Corp, East Hanover, NJ; 4The Permanente Medical Group/Kaiser Permanente, Oakland, CA; 5Yale Univ School of Medicine, New Haven, CT Yancy, et al HF Guidelines Circ 2013; 128: 240-327 21 22 khởi động HF bù vừa ổn định Slide Draft Presentation March 8, 2019 Background sau 8w sử dụng ARNI Double-blind Period Continued open-label sacubitril/valsartan In-hospital initiation of enalapril and continued for weeks after discharge Began open-label sacubitril/valsartan R Week In PIONEER-HF, weeks after randomization patients continued in a 4-week, open-label study with all patients receiving sacubitril-valsartan 23 Objectives • Describe changes in NT-proBNP among patients with HFrEF who were recently hospitalized forADHF switching from enalapril to sacubitril/valsartan Open-label Period In-hospital initiation of sacubitril/valsartan and continued f or weeks after discharge Slide Draft Presentation March 8, 2019 Week 12 • Compare the totality of clinical events, including rehospitalizations, during the 12-week study period by randomized treatment arm 24 NT-ProBNP giảm nhanh ARNI Slide Draft Presentation March 8, 2019 Slide Draft Presentation March 8, 2019 Patient Characteristics In-Hospital Initiation: Baseline Age* (years) Women (%) Black (%) No prior HF diagnosis (%) LVEF* NT-proBNP (pg/mL)* Open-Label Period: Week SBP (mm Hg)* NT-proBNP (pg/mL)* Change from Baseline in NT-proBNP Sacubitril/Valsartan (n=440) 61 (51, 71) 25.7 35.9 32.0 24 (18, 30) 2883 (1610, 5403) S/V to S/V (n=417) 118 (104, 129) 1218 (522, 3125) Enalapril (n=441) 63 (54, 72) 30.2 35.8 36.7 25 (20, 30) 2536 (1363, 4917) Enalapril to S/V (n=415) 120 (108, 133) 1630 (866, 3423) Reduction During Open-Label Study, Wk 8–12: In-hospital Enalapril to S/V:-35.8% (-30.6 to -40.7) In-hospital S/V to S/V:-18.5% (-11.8 to -24.7, P30ml/ph 50% ÀHF Chioncel O Eur J Heart Failure 2017; 19: 1574-1585 34 Behind every statistic is a personal journey… I A IIa C >30ml the eGFR is stable and >30 mL/min/1.73 m GLP1RAs (lixisenatide, liraglutide, semaglutide, exenatide, dulaglutide) IIb A 2019 ESC Guidelines Diabetes, have a neutral effect on the risk of HF hospitalization, and on may be pre-diabetes and cardiovascular diseases (European Heart Journal; 2019 - doi/10.1093/eurheartj/ehz486) considered for DM treatment in patients with HF Lifestyle and non–pharmaceutical/device/ surgical intervention tập cho mồ hôi … each one fraught by challenges too often caused by a lack of resources, inefficient health systems, or lack of education 35 Level and are recommended if the eGFR is stable and >30mL/min/1.73m Metformin should be considered for DM treatment in patients with HF, if 33 Class 36 Lifestyle and non–pharmaceutical/device/ surgical intervention Basic science: exercise and heart failure Progression of ET Start low and go slow “Gradual progression of exercise time, frequency and intensity is recommended for best adherence and least injury risk.” (ACSM) 37 thi: tình hướng cho, hỏi thêm gì, coi liều BB tối ưu chưa tăng liều 38 trước cho MRA lợi tiểu cho list thuốc kêu bỏ gì: vd thai bỏ RAS, hen bỏ BB hỏi tên nghiên cứu BB Putting it all together – delivering seamless, effective care Referral Source 2018 Cardiac Rheabilitation Dep IRCCS San Raffaele Hospital physicians Pharmacists General practitioners Cardiac rehabilitation Specialist advanced HF services Social services Nutritionists 39 40 ... viện suy tim tỉ lệ tử vong năm 8.1 1/3 nhập viện năm cut off 40% sau mốc tỉ lệ tử vong tăng vọt Survival curves in pts with EF > 40% vs EF < 40% 100 Mortality at year 8.1% Hosp at year 28% 80 học. .. nhanh HFr CCĐ: nhịp chậm, block av cao độ, RL nhịp thất, WPW, tim phì đại có tắc nghẽn ? ? 19 20 Slide Draft Presentation March 8, 2019 Heart Failure with Reduced EF Tried and True New and Improved... optimize treatment Tried and True học Initiate therapies during hospitalization for long-term use1 Marti NC et al Circ Heart Fail 2013;6:10951101 29 – – – – MRA có giảm nhập viện làm tăng suy