1 phong ngua, dieu tri som suy tim HN LK 2020 (8h25 8h45)

Phòng ngừa điều trị sớm suy tim PGS TS Nguyễn Văn Trí Đại học Y dược TP HCM P.Chủ tịch Hội Lão khoa Việt Nam Chủ tịch Hội Lão khoa TP HCM ĐÁI THÁO ĐƯỜNG MỆT NGỰC HOẶC KHÓ THỞ … SUY TIM ? Cận lâm sàng gì? ECG siêu âm tim Đủ loại trừ suy tim chưa ? PHÂN LOẠI SUY TIM 2016 ESC Guidelines Heart Failure1 New Heart Failure terminology : HFrEF, HFmrEF, HFpEF Type of HF HFrEF HFmrEF HFpEF Symptoms +/- Signs Symptoms +/- Signs Symptoms +/- Signs LVEF < 40% LVEF 40-49% LVEF ≥ 50% 1 - CRITERIA a b Changes ESC Guidelines 2012 ? Elevated levels of natriuretic peptides (NTproBNP > 125 ng/L) At least one additional criterion Relevant structural heart disease (LVH and/or LAE) Diastolic dysfunction 40% instead of 35% Ponikowski P et al (2016) European Heart Journal doi:10.1093/eurheartj/ehw128 New terminology HF : heart failure LAE : left atrial enlargement a b Elevated levels of natriuretic peptides (NTproBNP > 125 ng/L) At least one additional criterion Relevant structural heart disease (LVH and/or LAE) Diastolic dysfunction Addition of natriuretic peptides in diagnostic criterion LVEF : left ventricular ejection fraction LVH : left ventricular hypertrophy Đái tháo đường: Nguy độc lập dẫn đến suy tim • Diabetic and relative risk of developing HF compared with nondiabetics2 • Approximately 45% diastolic heart failure are in diabetic patients3 Potential mechanisms linking diabetes to HF5 Diabetes Endothelial dysfunction Hemostatic disorders Microangiopathy Myocardial fibrosis Abnormal metabolism CAD Diabetic cardiomyopathy HF Available at: http://diabetes.niddk.nih.gov/dm/pubs/stroke/ Last accessed Dcember 2012 Van der Horst et al (2010) Neth Heart J 18(4):190-196 Çiftel S et al., Diabetes Res Clin Pract, 96:179–86, 2012 Neuhold et al (2011) Eur J Clin Invest 41(12):1292-1298 Bauters et al (2003) Cardiovasc Diabetol 2:1-16 CAD: Coronary artery disease; HF: Heart failure Các thuốc chứng minh kéo dài sống Suy Tim PSTM giảm ACE-I: ức chế men chuyển ARBs: chẹn thụ thể angiotensin II ARNI: ức chế thụ thể angiotensin neprilysin TL: Ponikowski P 2016 ESC Guideline for the diagnosis and treatment of acute and chronic heart failure Eur H J, May 20, 2016 Dapagliflozin giảm 27% tần suất mắc Suy tim phổ rộng bệnh nhân ĐTĐ từ nguy TM thấp đến cao HR (95% CI) p-value 0.73 (0.61, 0.88) 125 pg/ml Exclusion: • History of cardiac disease • Signs of cardiac disease in the electrocardiogram • ST-T-wave abnormalities or a bundle branch block • Abnormal echocardiography … Allocation (n=300) Guideline-based treatment (n=150) Martin Huelsmann et al JACC 2013 Intensified treatment (n=150) 1) up titration of RAS antagonists and beta-blocker to maximal recommended dosage 2) Start ACEI if RAS antagonist or beta-blocker is not started 3) Increase dose of medication till NT-proBNP decreased by 50% or below normal range or a tolerated dose achieved years: hospitalization or death due to cardiac disease 12 PONTIAC trial: NT-proBNP guided prevention for Diabetes Result Martin Huelsmann et al JACC 2013 Intensified group (n=150) Control group (n=150) deaths deaths None due to cardiac disease out due to cardiac disease 13 2017 ACC/AHA HF Guideline 14 Yancy, et al 2017 ACC/AHA/HFSA Heart Failure Focused Update 2017 ACC/AHA HF Guideline 15 Yancy, et al 2017 ACC/AHA/HFSA Heart Failure Focused Update 2017 ACC/AHA HF Guideline Biomarkers Biomarkers for Diagnosis COR I LOE A Recommendation In patients presenting with dyspnea, measurement of natriuretic peptide biomarkers is useful to support a diagnosis or exclusion of HF Comment/ Rationale MODIFIED: 2013 acute and chronic recommendations have been combined into a diagnosis section 16 NT-proBNP predicts heart failure in diabetes Objective: examined the individual and combined effect of NT-proBNP, high-sensitivity cardiac troponin T (hs-cTnT), interleukin-6 (IL-6), and hs-CRP on the prediction of heart failure incidence or progression in patients with type diabetes Study design: case-cohort study, 11,140 patients with type diabetes at high risk of cardiovascular events who participated in Action in Diabetes and Vascular Disease: Preterax and DiamicronModified Release Controlled Evaluation (ADVANCE) study Toshiaki Ohkuma et al Cardiac Stress and Inflammatory Markers as Predictors of Heart Failure in Patients With Type Diabetes: The ADVANCE Trial.Diabetes Care Volume 40, September 2017 17 NT-proBNP predicts heart failure in diabetes NT-proBNP showed the strongest association with heart failure Toshiaki Ohkuma et al Cardiac Stress and Inflammatory Markers as Predictors of Heart Failure in Patients With Type Diabetes: The ADVANCE Trial.Diabetes Care Volume 40, September 2017 18 2017 ACC/AHA HF Guideline Yancy, et al 2017 ACC/AHA/HFSA Heart Failure Focused Update 19 Kết luận: ▪ Suy tim sớm có khó thở, khoảng 45% phân suất tống máu bảo tồn ▪ NT-proBNP GIÚP chẩn đoán sớm suy tim đặc biệt bệnh nhân HFpEF ▪ Phòng ngừa điều trị sớm suy tim cải thiện tiên lượng ... 60 Thay đổi NT-proBNP DAPA-HF: thay đổi NT-proBNP tháng thứ Baseline EMPEROR: thay đổi NT-proBNP tháng thứ 12 Vai trò NT-proBNP suy tim CHUỖI BỆNH LÝ TIM MẠCH NMCT TMCT RL nhịp tim & RL chức...ĐÁI THÁO ĐƯỜNG MỆT NGỰC HOẶC KHÓ THỞ … SUY TIM ? Cận lâm sàng gì? ECG siêu âm tim Đủ loại trừ suy tim chưa ? PHÂN LOẠI SUY TIM 2016 ESC Guidelines Heart Failure1 New Heart Failure... NT-proBNP predicts heart failure in diabetes Objective: examined the individual and combined effect of NT-proBNP, high-sensitivity cardiac troponin T (hs-cTnT), interleukin-6 (IL-6), and hs-CRP