Mục tiêu điều trị suy tim trước khi xuất viện

Objectives in the management of heart failure • Improve clinical status • Improve functional capacity and quality of life • Prevent hospital readmission • Reduce mortality... 3 key po

TỐI ƯU HOÁ ĐIỀU TRỊ SUY TIM MẠN

“Signed” by HFA / ESC/ HFSA/ ACC/ AHA

Downloaded from http://circ.ahajournals.org/ at Amgen, Inc on May 20, 2016

www.escardio.org/guidelines

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In the year 2016,… by applying all evidence-based

discoveries, heart failure is becoming a preventable

and treatable disease

Objectives in the management of heart failure

• Improve clinical status

• Improve functional capacity and quality of life

• Prevent hospital readmission

• Reduce mortality

3 key points

to optimize treatment of a patient with chronic heart failure

PATIENT’S JOURNEY

RIGHT TIMING

RIGHT ACTION

Heart failure patients suffer from recurrent hospitalization

1 Gheorghiade M et al Am J Cardiol 2005;96:11-17

With each hospitalization, there is likely myocardial and renal damage

which contributes to progressive left ventricular or renal dysfunction, leading to an inevitable downward spiral 1

Patients are stable by discharge

“It is important to consider that once hospitalized heart failure patients are stabilized by discharge, the majority of them should be considered to be in

outcomes.” 1

1 Gheorghiade M et al Recognizing hospitalized heart failure as an entity and developing new therapies to improve outcomes Academics’, clinicians’, industry’s, regulators’, and payers’ perspectives Heart Failure Clin 2013.9;285-290

Post-discharge, the prognosis is poor

“Hospitalized heart failure is associated with unacceptable high

1 Gheorghiade M et al Recognizing hospitalized heart failure as an entity and developing new therapies to improve outcomes Academics’, clinicians’, industry’s, regulators’, and payers’ perspectives Heart Failure Clin 2013.9;285-290

Mortality is particularly high

in the early phase after hospitalization

1. Marti NC et al.Timing and duration of interventions in clinical trials for patients with hospitalized heart failure Circ Heart Fail 2013;6:1095-1101 - Changes in risk profile after hospitalization Hazard ratio of all-cause mortality after discharge from hospital for first hospitalization

All-cause mortality after discharge for HF is high during the 1 st month 1

Time after discharge from hospital (months)

Rehospitalization is particularly high

in the early phase after hospitalization:

1 out of 2 patients rehospitalized within 2 months

1. O’Connor CM et al Causes of death and rehospitalization in patients hospitalized with worsening heart failure and reduce left ventricular ejection fraction: results from efficacy of vasopressin antagonism in heart failure outcome stuy with tolvaptan (EVEREST) program Am Heart J 2010;159:841-849.e1

EVEREST

Timing of major causes

of first hospitalization1

[2159 patients]

The high risk in the weeks to months post-discharge

1. Krumholz HM Post-hospital Syndrome – An acquired, Transient Condition of Generalized Risk NEJM 2013;368;2

2. Marti NC et al Timing and duration of interventions in clinical trials for patients with hospitalized heart failure Circ Heart Fail 2013;6:1095-1101

The post-discharge period is described as an “acquired, transient condition of generalized risk” or “a period of vulnerability.” 1

Comprehensive strategies should focus on factors during hospitalization and also during the early recovery period soon after discharge to target stressors that probably contribute to the vulnerability of patients 1,2

Post-discharge follow-up & survival

1. Metra M et al Postdischarge assessment after a heart failure hospitalization: the next step forward Circulation 2010;122:1782-1785

A review of post-discharge

assessment (30 days)

in more than 10 500

patients from the National

Ambulatory Care Reporting

System (Canada) 1

Death (% of patients)

Hospitalization is the key moment

to optimize treatment

to prevent post-discharge mortality and rehospitalization

1 Psotka MA, Teerlink JR Strategies to Prevent Postdischarge Adverse Events Among Hospitalized Patients with Heart Failure Heart Failure Clin 2013;9:303-320

Prevention of adverse outcomes in hospitalized HF patients relies on preventing HF progression by: 1

initiating and titrating evidence-based therapy ensuring continued adherence to that therapy preventing and treating patient comorbidities

Hospitalization is the key moment

to optimize treatment

2013 ACCF/ AHA guidelines for HF

1 Yancy C et al 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Circulation 2013;128:e240-e327

Recommendations for hospital discharge 1

www.escardio.org/guidelines

Therapeutic algorithm for

a patient with

Elevated heart rate at hospital discharge

1 Logeart D et al Raised heart rate at discharge after acute heart failure is an independent predictor of one-year mortality Eur Heart J 2012;33(Abst Suppl):485 [ABSTRACT]

HR Reduction as a Therapeutic Target

Reduce myocardial oxygen consumption

Improve contractile performance

Improve diastolic filling

Reduce risk of VF and sudden death

Promote reverse remodeling

BUT…Beta-blockers remain underutilized and

underdosed in clinical practice (and in trials)

Kitai et al., Curr Treat Options Cardio 2016;18:13

Underutilization of Beta-Blockers

Gheorghiade et al, Cong Heart Fail 2012;18:9

Practical guidance on the use of beta-blockers in

patients with heart failure

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Optimization of treatment before discharge

Pharmacological treatment in CHF recommended in the 2016 ESC guidelines

1. McMurray J et al European Society of Cardiology Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 Eur Heart J 2012;33:1787-1847

1

ETHIC-AHF: effects of the early co-administration

of ivabradine and beta-blockers in patients with heart failure

2016 ESC GUIDELINES

Recommendations for initial management of

a rapid ventricular rate

in patients with heart failure and atrial

fibrillation in the acute

or chronic setting

Guidelines that aren’t implemented don’t work

3 key points

to optimize treatment of a patient with chronic heart failure

PATIENT’S JOURNEY

RIGHT TIMING

RIGHT ACTION