SUY TIM: CÁC BIỆN PHÁP ĐIỀU TRỊ MỚI Ths BSNT Nguyễn Thị Minh Lý Trung tâm Tim mạch

SUY TIM: CÁC BIỆN PHÁP ĐIỀU TRỊ MỚI Ths BSNT Nguyễn Thị Minh Lý Trung tâm Tim mạch - BV ĐHYHN Bộ môn Tim mạch - ĐHYHN ĐỊNH NGHĨA SUY TIM “ Suy tim hội chứng lâm sàng hệ bất thường cấu trúc chức tim dẫn đến giảm khả đổ đầy tống máu tâm thất” ACC/AHA Guidelines 2013 Burden of Heart Failure • • • Lifetime risk > 20% for Americans >40 years of age 870,000 new cases diagnosed annually Prevalence in US: 5.7 million TRIỆU CHỨNG LÂM SÀNG • Suy tim trái: Khó thở gắng sức  Khó thở nghỉ ngơi  Khó thở nằm  Cơn khó thở kịch phát đêm (PND)  Mệt, khơng có khả gắng sức Suy tim phải:  Phù chân  Cổ chướng, chướng bụng  Tức nặng hạ sườn phải  Chán ăn  Sút cân  • ACC/AHA Guidelines 2013 TRIỆU CHỨNG THỰC THỂ • Suy tim trái Nghe có rale ẩm phổi • Tràn dịch màng phổi • Mỏm tim đẩy lệch xuống thấp • Tim đập nhanh, tiếng T3 ngựa phi, tiếng thổi tâm thu hở van hai • Huyết áp kẹt Suy tim phải: • Phù chân • Tăng áp lực tĩnh mạch trung tâm • Tiếng ngựa phi phải, thổi tâm thu hở van ba • Cổ chướng, dịch màng phổi • • ACC/AHA Guidelines 2013 CÁC GIAI ĐOẠN SUY TIM Không triệu chứng A At high risk for HF but without structural heart disease or symptoms of HF (e.g., patients with HTN or CAD) B Structural heart disease but without symptoms of HF Phân độ NYHA Class I Asymptomatic: No limitation of physical activity Ordinary activity does not cause sxs II Symptomatic with moderate exertion C Structural heart disease with prior or current symptoms of HF Ordinary physical activity causes SOB, fatigue III Symptomatic with minimal exertion Less than usual activity causes sxs D Refractory/advanced HF requiring specialized interventions IV Symptomatic at rest Unable to carry on any activity without discomfort Có triệu chứng ACC/AHA Guidelines 2013 PHÂN ĐỘ NYHA VÀ TỶ LỆ TỬ VONG Độ NYHA Class I Asymptomatic: No limitation of physical activity Ordinary activity does not cause sxs II Symptomatic with moderate exertion Tỷ lệ tử vong năm 5-10% 5-10% Ordinary physical activity causes SOB, fatigue III Symptomatic with minimal exertion Less than usual activity causes sxs IV Symptomatic at rest Unable to carry on any activity without discomfort 10-25% 25-60% ACC/AHA Guidelines 2013 Các nhóm suy tim: khuyến cáo ACC/AHA 2013 Định nghĩa suy tim dựa phân suất tống máu thất trái (EF): • Suy tim có EF giảm (HFrEF, EF ≤40%) • Suy tim có EF bảo tồn (HFpEF, EF ≥50%) • HFpEF, ranh giới (EF 41-49%) • HFpEF, cải thiện (EF >40%) Yancy CW, Jessup M, Bozkurt B, 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 ACC/AHA Guidelines 2013 ĐIỀU TRỊ BỆNH NHÂN SUY TIM At Risk for Heart Failure STAGE A At Risk for Heart Failure STAGE A STAGE B At high risk for HF but without structural heart disease or symptoms of HF Structural heart disease but without signs or symptoms of HF e.g., Patients with: · HTN · Atherosclerotic disease · DM · Obesity · Metabolic syndrome or Patients · Using cardiotoxins · With family history of cardiomyopathy Structural heart disease STAGE B At high risk for HF but without structural heart disease or symptoms of HF STAGE C Structural heart disease Heart Failure but without signs or symptoms of HF e.g., Patients with: · HTN · Atherosclerotic disease e.g., Patients with: · DM · Previous MI e.g., Patients with: · Obesity Development of · LV remodeling including heart · Known structural Structural heart disease and HF of symptoms LVH and low EF · Metabolic syndrome · HF signs and symptoms disease · Asymptomatic valvular or disease Patients · Using cardiotoxins · With family history of HFpEF HFrEF cardiomyopathy THERAPY Goals · Heart healthy lifestyle · Prevent vascular, coronary disease · Prevent LV structural abnormalities THERAPY Goals · Prevent HF symptoms · Prevent further cardiac Drugs · ACEI or ARB in appropriate patients for vascular disease or DM · Statins as appropriate appropriate · Beta blockers as appropriate remodeling Drugs · ACEI or ARB as In selected patients · ICD · Revascularization or valvular surgery as appropriate STAGE D Structural heart disease with prior or current symptoms of HF THERAPY Goals · Control symptoms · Improve HRQOL · Prevent hospitalization · Prevent mortality THERAPY Goals Strategies · Identification of comorbidities · Heart healthy lifestyle · Prevent vascular, Treatment Diuresis to relieve symptoms coronary· disease of congestion · Prevent LV structural · Follow guideline driven indications for comorbidities, abnormalities e.g., HTN, AF, CAD, DM · Revascularization or valvular surgery as appropriate Drugs · ACEI or ARB in appropriate patients for vascular disease or DM · Statins as appropriate Refractory HF e.g., Patients with: e.g., Patients · Previous MI with: Refractory · Marked HF symptoms at symptoms of HF · LV remodeling including rest at rest, despite GDMT LVH and lowhospitalizations EF · Recurrent despite GDMT valvular · Asymptomatic disease THERAPY Goals · Control symptoms · Patient education · Prevent hospitalization · Prevent mortality Drugs for routine use · Diuretics for fluid retention · ACEI or ARB · Beta blockers · Aldosterone antagonists THERAPY Goals · Control symptoms · Improve HRQOL · Reduce hospital readmissions ·THERAPY Establish patient’s endof-life goals Goals Options · Prevent HF symptoms · Advanced care measures · Prevent further cardiac · Heart transplant Drugs for use in selected patients · Hydralazine/isosorbide dinitrate · ACEI and ARB · Digoxin In selected patients · CRT · ICD · Revascularization or valvular surgery as appropriate · Chronic inotropes remodeling · Temporary or permanent MCS · Experimental surgery or Drugs drugs · Palliative care and · ACEI or ARB as hospice · ICD deactivation appropriate · Beta blockers as appropriate In selected patients · ICD · Revascularization or 2013 ACCF/AHA Guideline for the Management Heart as Failure valvularofsurgery STAGE A STAGE B At high risk for HF but without structural heart At Risk for Heart Failure isease or symptoms of HF STAGE A At high risk for HF but Patients with: heart without structural disease or symptoms of HF STAGE Structural heart disease but without signs or symptoms of HF Heart Failure STAGE B STAGE C Structural heart disease but without signs or symptoms of HF Structural heart disease with prior or current symptoms of HF g., HTN Atherosclerotic disease e.g., Patients with: DM e.g., Patients with: · HTN · Previous MI Obesity Development of · Atherosclerotic disease · LV remodeling including e.g., Patients with: Structural heart · DM syndrome Metabolic symptoms of HF e.g., Patients with: disease· Previous MI LVH and oflow EF · Obesity Development · LV remodeling including Structural heart · Known structural heart disease and or · Metabolic syndrome symptoms of HF · Asymptomatic valvular disease LVH and low EF · HF signs and symptoms or atients · Asymptomatic valvular disease Patients disease Using·cardiotoxins Using cardiotoxins · With family history of With family history of cardiomyopathy cardiomyopathy HFpEF THERAPY Goals · Heart healthy lifestyle THERAPY · Prevent vascular, Goals coronary disease Prevent LV structural Heart ·healthy lifestyle abnormalities Prevent vascular, Drugs disease coronary · ACEI or ARB in Preventappropriate LV structural patients for vascular disease or DM abnormalities · Statins as appropriate rugs ACEI or ARB in appropriate patients for vascular disease or DM Statins as appropriate THERAPY Goals · Prevent HF symptoms · Prevent further cardiac remodeling Drugs · ACEI or ARB as appropriate · Beta blockers as appropriate In selected patients · ICD · Revascularization or valvular surgery as appropriate THERAPY Goals · Control symptoms THERAPY · Improve HRQOL Goals · Prevent hospitalization · Prevent mortality · Prevent HF symptoms · Prevent further Strategies cardiac · Identification of comorbidities remodeling Treatment Drugs · Diuresis to relieve symptoms of congestion · ACEI or ARB as · Follow guideline driven appropriate indications for comorbidities, e.g., HTN, · Beta blockers asAF, CAD, DM · Revascularization or valvular appropriate surgery as appropriate In selected patients · ICD · Revascularization or valvular surgery as appropriate Structural hear with prior or symptoms STAGE D Refractory HF e.g., Patients with: · e.g., Known structural he Patients with: Refractory Marked HF symptoms signs and atsympt symptoms of HF · ·HF at rest, despite GDMT rest · Recurrent hospitalizations despite GDMT HFrEF THERAPY Goals · Control symptoms · Patient education · Prevent hospitalization Goals · Prevent mortality HFpEF THERAPY Goals · Control symptoms · Improve HRQOL THERAPY · Reduce hospital readmissions · Establish patient’s endsymptoms of-life goals Drugs for routine · useControl · Diuretics for fluid retention · Improve HRQOL Options · ACEI or ARB · Advanced care · Beta blockers · Prevent hospitalization measures · Aldosterone antagonists · Prevent mortality · Heart transplant · Chronic inotropes Drugs for use in selected patients · Temporary or permanent · Hydralazine/isosorbide dinitrate MCS · ACEI and ARB Strategies · Experimental surgery or · Digoxin drugs · Identification of comorbidities · Palliative care and In selected patients hospice · CRT · ICD deactivation · ICD Treatment · Revascularization or valvular surgery as appropriate · Diuresis to relieve symptoms of congestion · Follow guideline driven indications for comorbidities, e.g., HTN, AF, CAD, DM · Revascularization or valvular surgery as appropriate G · · · · D · · · · D · · · I · · At Risk for Heart Failure A HF but l heart ms of HF heart sease me s y of style , ural nts for or DM priate Heart Failure STAGE B STAGE C e.g., Patients with: Structural heart disease Structural heart disease but without signs or with prior or current · Previous MI e.g., Patients with: At Risk for Heart Failure symptoms of HFDevelopment symptoms of HF of · LV remodeling including · Known structural heart disease and symptoms of HF STAGE A STAGE B LVH and low EF · HF signs and symptoms STAGE C At high risk for HF but Structural heart disease Structural heart disease · Asymptomatic without structural heart valvular but without signs or with prior or current disease or symptoms of HF symptoms of HF symptoms of HF disease e.g., Patients with: · Previous MI Development of Structural heart e.g., Patients with: · LV remodeling including symptoms of HF LVH and low EF ·disease HTN · Atherosclerotic disease · Asymptomatic valvular e.g., Patients with: · DM disease · Previous MI · Obesity · Metabolic syndrome or Patients · Using cardiotoxins · With family history of cardiomyopathy Structural heart disease THERAPY Goals THERAPY · Prevent HF symptoms Goals · Prevent HF symptoms · Prevent further cardiac THERAPY remodeling · Prevent further cardiac remodeling Goals · Heart healthy lifestyle Drugs · Prevent vascular, coronary disease · ACEI or ARB as appropriate ACEI ARB as · Prevent LV or structural · Beta blockers as abnormalities appropriate appropriate Drugs · · DrugsBeta blockers as In selected patients · ACEI or ARB in appropriate ICD appropriate patients·for Revascularization or vascular disease or ·DM · Statins as appropriatevalvular surgery as appropriate In selected patients · ICD · Revascularization or valvular surgery as appropriate e.g., Patients with: · Known structural heart disease and · HF signs and symptoms Development of HFpEF symptoms of HF · LV remodeling including LVH and low EF · Asymptomatic valvular disease THERAPY HFpEF STAGE D Patients with: e.g., Refractory Refractory HF Heart Failure symptoms of HF · Marked HF symptoms a rest at rest, despite GDMT STAGEhospitalization D · Recurrent Refractory HF despite GDMT Refractory symptoms of HF at rest, despite GDMT e.g., Patients with: · Known structural heart disease and · HF signs and symptoms HFrEF THERAPY HFrEF Goals THERAPY · Control symptoms Goals · Patient education HFpEF HFrEF · Control symptoms · Patient education · Prevent hospitalization · Prevent hospitalization THERAPY THERAPY · Prevent mortality · Prevent mortality Goals e.g., Patients with: · Marked HF symptoms at rest · Recurrent hospitalizations despite GDMT e.g., Patients with: Refractory symptoms of HF at rest, despite GDMT · Marked HF symptoms at rest · Recurrent hospitalizations despite GDMT THERAPY Goals THERAPY · Control symptoms Goals · Improve HRQOL · Control symptoms · Improve HRQOL · Reduce hospital · Reduce hospital THERAPY readmissions readmissionsGoals ··Control symptoms · Establish patient’s endEstablish patient’s endof-life goals · Improve HRQOL of-lifehospital goals · Reduce Goals THERAPY · Control Goalssymptoms · Control symptoms · Improve HRQOL · Improve HRQOL THERAPY · Prevent hospitalization · Prevent hospitalization Goals Goals · Control symptoms · Prevent mortality · Control symptoms · Prevent · Prevent HF symptoms mortality · Patient education Drugs for routine use · Prevent further cardiac · Improve HRQOL Drugs for routine usehospitalization Prevent · Diuretics for fluid·retention remodeling Strategies · Prevent hospitalization readmissions · Prevent mortality Options · ACEI or ARB for · Diuretics fluid retention · Establish patient’s end· Identification of comorbidities · Prevent mortality Strategies · Advanced care · Beta blockers Drugs for routine use of-life goals Drugs · ACEI orantagonists ARB measures Options · Aldosterone · Diuretics for fluid retention · ACEI or · ARB as Identification Strategies · Heart transplant · Advanced care Treatment of comorbidities · Beta blockers Options · ACEI or ARB appropriate · Chronic inotropes for use in selected patients · Identification ofDrugs comorbidities · Advanced care · Beta blockers measures · Aldosterone antagonists · Beta blockers as· Diuresis to relieve symptoms · Temporary or measures permanent · Hydralazine/isosorbide dinitrate · Aldosterone antagonists of congestion appropriate MCS · ACEI and ARB Heart transplant ··Heart transplant Treatment Treatment · Follow guideline driven · Experimental· surgery or Chronic inotropes Drugs for use in selected patients · Digoxin · Diuresis to relieve symptoms · Chronic Drugs for use in selected patients In selected · Temporary orinotropes permanent · Hydralazine/isosorbide dinitrate drugs indications for comorbidities, · patients Diuresis to relieve symptoms of congestion MCS · ACEI and ARB · ICD · Palliative care and In selected patients · Temporary or permanen · Hydralazine/isosorbide dinitrate e.g., HTN, AF, CAD,· DM Follow guideline driven · Experimental surgery or · Digoxin of congestion · Revascularization hospice · CRT · or Revascularization or valvular MCS · ACEI and ARB indications for comorbidities, drugs valvular surgery as · ICD deactivation ICD surgery as appropriate ··Palliative care and surgery or In or selected patients · Follow guideline drivene.g., HTN, AF, ··CAD, DM appropriate Experimental Revascularization valvular · Digoxin hospice · CRT · Revascularizationsurgery or valvular as appropriate · ICD deactivation indications for comorbidities, · ICD drugs surgery as appropriate · Revascularization or valvular · Palliative care and In selected patients e.g., HTN, AF, CAD, DM surgery as appropriate hospice · CRT · Revascularization or valvular · ICD deactivation · ICD surgery as appropriate · Revascularization or valvular surgery as appropriate THĂM DỊ CLS SUY TIM GIAI ĐOẠN C • • Sau hỏi tiền sử chi tiết; làm XN ban đầu: • CTM,TPT nước tiểu, Canxi, Magie, lipid máu lúc đói, TSH, sắt Theo dõi định kỳ bao gồm: điện giải chức thận • ĐTĐ 12 chuyển đạo làm ban đầu bệnh nhân có triệu chứng suy tim • X quang tim phổi thẳng BN khởi phát suy tim • • Siêu âm tim bệnh nhân chẩn đoán suy tim Siêu âm tim lặp lại BN có thay đổi rõ rệt lâm sàng cân nhắc thay đổi điều trị đánh giá cho điều trị cấy máy • Các thăm dị hình ảnh gắng sức khơng xâm lấn thơng tim thực BN suy tim nghi có bệnh mạch vành BNP (NT-proBNP) • BNP B-type natriuretic peptide sản xuất chủ yếu tâm thất đáp ứng với tình trạng căng giãn tim • BNP có tác dụng giãn mạch, lợi tiểu, thải natri  ích lợi BN suy tim • nồng độ tăng BN bị suy tim, có tương quan với áp lực cuối tâm trương thất trái tiên lượng • BNP < 100 pg/ml loại trừ suy tim trường hợp khó thở cấp BNP (NT-proBNP) (2) • BN viện có nồng độ BNP > 400-500 pg/ml có nguy cao tái nhập viện suy tim tử vong • BN suy tim với EF thấp điều trị lợi tiểu đầy đủ có nồng đồ NT- Pro BNP giới hạn bình thường (2025% trường hợp suy tim mạn tính) • Nồng độ ↑ theo tuổi, đặc biệt nữ giới lớn tuổi, BN có suy thận •↑ cao BN suy tim có EF giảm so với EF bảo tồn •Tăng BNP BN suy thất phải nhồi máu phổi •↓ ↓ BN béo phì Giai đoạn C (HFrEF & HFpEF) • Can thiệp khơng dùng thuốc • Giáo dục tự chăm sóc • Phục hồi chức năng, hoạt động thể lực đặn • Hạn chế muối • Điều chỉnh bệnh tật kèm theo: THA, đái tháo đường, bệnh mạch vành, ngừng thở ngủ, thiếu máu • Tiêm phịng cúm phế cầu • Giảm/ngừng uống rượu, hút thuốc sử dụng chất kích thích khác • Theo dõi sát bệnh nhân ngoại trú • Tránh sử dụng số nhóm thuốc: • CVKS • Thuốc chẹn kênh Ca, ngoại trừ amlodipine (trong suy tim giảm EF) • Các thuốc chống loạn nhịp, ngoại trừ amiodarone, dofetalide • Thuốc điều trị đái tháo đường:Thiazolidinediones (TZDs) SINH LÝ BỆNH SUY TIM GIẢM EF VÀ ĐÍCH ĐIỀU TRỊ SNS LV remodeling SNS= sympathetic nervous system RAAS= Renin angiotensin aldosterone system Adapted from Langenickel TH, Dole WP Drug Discovery Today 2012;9:131–9 HFrEF: Thuốc thiết bị ↓ Symptoms ↓ Hospitalizations ↓ Mortality Diuretics √ √ (?) ? ACE I /ARBs √ √ √ Beta-Blockers √ √ √ Aldosterone Antagonists √ √ √ Digitalis √ √ X Nitrates/Hydralazine √ √ √ ARNI √ √ √ Ivabradine √ √ X AICD (Defibrillators) X X √ CRT (BiV pacemakers) √ √ √ CÁC THUỐC LỢI TIỂU THƯỜNG DÙNG Điều trị nội khoa HFrEF gđ C: Lợi ích qua thử nghiệm lâm sàng RR ↓ Mortality NNT to ↓ mortality (standardized 36 months) RR ↓ HF Hospital ACE I / ARB 17% 26 31% Beta-Blockers 34% 41% Aldosterone Antagonists 30% 35% Nitrates/Hydralazine 43% 33%