Suy tim với chức năng tâm thuthất trái bảo tồnNhững vấn đề còn thách thức

Suy tim với chức tâm thu thất trái bảo tồn Những vấn đề thách thức TS.BS Hoàng Văn Sỹ Đại học Y Dược Tp Hồ Chí Minh Khoa Nội Tim mạch BV Chợ Rẫy TP HCM 13/7/2019 Tần suất suy tim với EF bảo tồn (HFpEF) Khoảng ½ bệnh nhân suy tim có triệu chứng là suy suy tim EF bảo tồn In patients with clinical HF, the prevalence of HFpEF is estimated to be approximately 50%1 The proportion of incident cases of HFpEF increased from 47.8% in 2000–2003 to 52.3% in 2008–20102 Patients with HFpEF were older and more likely to be female than those with HFrEF3a Vào 2020, ước đoán 65% suy tim nhập viện suy tim EF bảo tồn4 aThe GWTG-HF registry was merged with claims from the U.S Centers for Medicare and Medicaid Services (CMS) from January 1, 2005, through December 30, 2009, with years of follow-up through the end of December 2014 HF, heart failure; HFrEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction Yancy CW et al Circulation 2013;128:e240-e327; Gerber Y et al JAMA Intern Med 2015;175(6):996-1004; Shah KS et al J Am Coll Cardiol 2017;70(20):2476-2486; Oktay AA et al Curr Heart Fail Rep 2013; 10(4): doi:10.1007/s11897-013-0155-7 Định nghĩa loại suy tim theo ESC Cơ chế bệnh sinh chưa rõ ? Suy tim EF bảo tồn biểu bệnh ? Hypertension and coronary artery disease are major risk factors for development of heart failure Age Smoking LV enlargement Systolic dysfunction Dyslipidemia HFrEF CAD/MI Hypertension HFpEF Obesity Diabetes Normal LV structure and function LV hypertrophy LV remodeling Years Diastolic dysfunction Subclinical LV dysfunction HFrEF is also called systolic HF, although patients may also exhibit diastolic abnormalities HFpEF is also called diastolic HF, although most patients have evidence of both systolic and diastolic dysfunction Clinical HF Years/months CAD, coronary artery disease; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; LV, left ventricular; MI, myocardial infarction Krum H, Gilbert RE Lancet 2003;362:147–58; Borlaug BA, Paulus WJ Eur Heart J.2011;32:670–679 Sinh bệnh học HFpEF Các chế SBH trung ương và ngoại vi Suy tim EF bảo tồn biểu nhiều bệnh ? • Heterogeneity of patient characteristics, organsystem involvement and number of pathophysiological abnormalities suggest a multifactorial etiology in patients with HFpEF • Subphenotypes in HFpEF are usually described according to the most dominant clinical characteristics: • HFpEF subphenotype with PAH and RV dysfunction has been well characterized and signifies advanced stage HF Peripheral Mechanisms Pulmonary Pulmonary venous hypertension ± Impaired diffusion capacity ± ‘Reactive’ arterial hypertension LV Diastolic Stiffening and Dysfunction LV Filling Pressures Renal Sodium retention RV Filling Pressures Endothelial dysfunction AF and LA Dysfunction Autonomic dysfunction Central Mechanisms Exercise tolerance RV Dysfunction Load sensitivity Arterial Stiffening LV Systolic Stiffening and Dysfunction Coronary and systemic microvascular rarefaction Skeletal muscle Myopathy AF, atrial fibrillation, LA, left atria; LV, left ventricular; RV, right ventricular; HFpEF, heart failure with preserved ejection fraction; PAH, pulmonary arterial hypertension Zakeri R and Cowie MR Heart 2018;104(5):377-384 Kiểu hình lâm sàng và bệnh lý kèm HFpEF Tăng huyết áp yếu tố nguy HFpEF1 The most commonly encountered clinical phenotypes of HFpEF include hypertension (identified as the core risk factor), aging, obesity, pulmonary hypertension, and CAD1,2 These clinical phenotypes further share comorbid conditions that include atrial fibrillation, anemia, COPD, frailty, diabetes, obstructive sleep apnea, and CKD2 Anemia Atrial Fibrillation CAD COPD Aging Hypertension Frailty PH • Aging-related comorbid conditions include atrial fibrillation, anemia, COPD and frailty Obesity • Obesity-related comorbid conditions include diabetes, obstructive sleep apnea and CKD Defining clinical phenotypes could be essential for management of patients with HFpEF leading towards therapeutic progress CKD Diabetes Obstructive sleep apnea CAD, coronary artery disease, CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; HFpEF, heart failure with preserved ejection fraction; PH, pulmonary hypertension Yancy CW et al Circulation 2013;128:e240-e327 Samson R et al J Am Heart Assoc 2016;5(1):e002477 doi:10.1161/JAHA.115.002477 Chẩn đốn HFpEF khó khăn ? Chẩn đốn suy tim EF bảo tồn dựa chế hay dựa khía cạnh lâm sàng ? Dựa chế1: Áp lực động mạch phổi bít Zakeri R, Cowie MR Heart2018;0:1–8 doi:10.1136/heartjnl-2016-310790 Kishan S, et al JACC: HEART FAILURE VOL.6,NO.8,2018 Chẩn đốn HFpEF khó khăn ? Chẩn đoán suy tim EF bảo tồn dựa chế hay dựa khía cạnh lâm sàng ? Dựa lâm sàng1: ▪ Obese HFpEF/HFpEF with pulmonary vascular disease ▪ HFpEF with arterial stiffening ▪ HFpEF with endothelial dysfunction Zakeri R, Cowie MR Heart2018;0:1–8 doi:10.1136/heartjnl-2016-310790 Kishan S, et al JACC: HEART FAILURE VOL.6,NO.8,2018 Triệu chứng và dấu hiệu HFpEF Triệu chứng tương tự suy tim EF giảm The main differences are that patients with HFpEF have lower rates of acute pulmonary edema and paroxysmal nocturnal dyspnea 120 Patients (%) 100 P = 0.11 96.2 94.9 80 P = 0.06 60 46.4 P = 0.007 42.5 40 P = 0.02 30.1 25 21.1 20 17.3 Dyspnea or shortness of breath Orthopnea Reduced ejection fraction (50%) (n=880) HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; S3, third heart sound; S4, fourth heart sound Bhatia RS, et al N Engl J Med 2006;355(3):260–269 Triệu chứng và dấu hiệu HFpEF Triệu chứng tương tự suy tim EF giảm The main differences are that patients with HFpEF have lower rate of S3 heart sounds and chest radiographic signs and a higher rate of bilateral ankle edema P = 0.95 90 Patients (%) 80 84.3 84.4 P