Op#misa#on du traitement dans l insuffisance cardiaque en 2018? Richard Isnard Hôpital Pi#é- Salpêtrière Sorbonne- Université Paris
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1 Op#misa#on du traitement dans l insuffisance cardiaque en 2018? Richard Isnard Hôpital Pi#é- Salpêtrière Sorbonne- Université Paris
2 Déclaration de Relations Professionnelles Disclosure Statement of Financial Interest J'ai actuellement, ou j'ai eu au cours des deux dernières années, une affiliation ou des intérêts financiers ou intérêts de tout ordre avec une société commerciale ou je reçois une rémunération ou des redevances ou des octrois de recherche d'une société commerciale : I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Affiliation/Financial Relationship Grant/Research Support Consulting Fees/Honoraria Company Servier Novartis Vifor Resmed Pfizer Boehringer Bayer Thoratec Menarini
3 Heart failure: an «epidemy» of the 21rd century Discharges in Thousands Years Percent of Population Age ( Years) Male Female Male Female Figure 1 Discharges From Hospitalization Due to Heart Failure, by Sex (United States, ) Figure 2 Prevalence of Heart Failure, by Sex and Age (National Health and Nutrition Examination Survey, ) Lifetime risk of developing heart failure 20 % (Framingham) Braunwald, JACC Heart Failure 2013 Llyod-Jones, Circulation 2003
4 Standardised incidence - 7 % Crude incidence + 12 % ESTIMATED PREVALENCE INCREASED BY 23 % from 2002 to 2014 Conrad, Lancet 2018
5 Prognosis of Heart Failure in France Tribouilloy C et al. Eur Heart J 2008;29: year survival < 50 %
6 2 y- mortality a]er a first hospitaliza#on for HF Tuppin, Arch Cardiovasc Dis 2014
7 Mortality a]er discharge from HF hospitaliza#on Hazard ratio T i m e a f ter discharge from hospital ( m on t hs) No. d e a t hs N o H F h o sp i talizat i on Solomon, Circula#on 2007
8 J Am Coll Cardiol 2018
9 Les 10 ques#ons- clés 1. Comment ini#er, ajouter, remplacer, #trer les médicaments recommandés? 2. Quels ou#ls pour aider à op#miser? 3. Quand adresser à un spécialiste de l IC? 4. Comment améliorer la coordina#on des soins? 5. Comment améliorer l observance? 6. Quid de certains pa#ents (sujets âgés, fragiles ) 7. Comment prendre en compte le coût du TTT 8. Comment prendre en charge la complexité croissante de l IC 9. Comment prendre en charge les comorbidités? 10. Comment intégrer les soins pallia#fs?
10 Ques#on 1 Comment ini#er, ajouter ou remplacer, #trer les traitements recommandés?
11 European Guidelines 2016
12
13
14
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16 PARADIGM- HF age 18 years NYHA class II, III ou IV LV EF 40% (amendtement modified value " 35%») BNP 150pg/ml ou NT- probnp 600pg/ml BNP 100pg/ml (ou NT- probnp 400pg/ml), if previous hospitalisa#on for heart failure in the last 12 months pauents already treated by ACE- i ou ARB whatever the dose but pa#ent should receive a stable dose of beta- blockers and a dose of ACE- I or ARB at least equivalent to 10 mg enalapril / day during the 4 last weeks preceding the randomiza#on.
17
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19 Design de Paradigm
20 Run- in: 2079 (19.8 %) discon#nued 1102 (10.5 %) enalapril 977 (9.3 %) LCZ696 2/3 for adverse events Hypotension Hyperkaliemia Worsening renal func#on Angioedema (0.2 %) = 25 pa#ents Desai, Circ Heart Fail 2016
21 Mul#variate predictors of dropout before randomisa#on Desai, Circ Heart Fail 2016
22
23 Op#misa#on du traitement Ini#a#on Intensifica#on stabilisa#on T0 2-4 mois cycle 1-4 sem 3 mois
24 Phases du traitement de l ICA Ini#ale Urgences /USIC Stabilisa#on Sor#e Hémodynamique Oxygéna#on Introduc#on /adapta#on TTT long terme Traitement Observance Educa#on / suivi Environnement
25 Comment expliquer l iner#e thérapeu#que? Visites non planifiées après la sor#e d hôpital. le MG n est pas à l aise avec les médicaments de l IC la disponibilité du cardiologue est limitée Percep#on de la part du médecin d une «stabilité clinique» crainte de donner des effets indésirables Ré#cence des pa#ents à prendre les médicaments (notamment les nouveaux ) à augmenter les doses Obstacles réels: hypotension, dysfonc#on rénale, hyperkaliémie
26 Ques#on # 2 Quels ou#ls pour aider à op#miser?
27 Suivi clinique / 3-6 mois, plus souvent ini#alement Bio: créa#nine, kaliémie Echocardiographie Ini#ale 3-6 mois après op#misa#on => CRT ou DAI BNP / NTproBNP diagnos#c / pronos#c réponse au traitement mesures répétées pour intensifier le TTT = NON A en#on si sacubitril /valsartan préférer le NT- probnp
28 Ques#on # 3 Quand référer au spécialiste IC?
29
30 Ques#on # 4 Comment améliorer la coordina#on des soins?
31 Laveau, Arch Cardiovasc Dis 2017
32 préparer / an#ciper la sor#e Le pa#ent est- il suffisamment amélioré? poids / dyspnée / oedèmes natrémie / créa#nine / NT probnp / bilan hépa#que Quid des traitements médicamenteux? Les bonnes classes médicamenteuses Doses de furosémide? Quid de l informa#on? Educa#on? Le parcours ultérieu r est- il balisé? qui va le revoir? qui va #trer les médicaments? Projet de réadapta#on? d éduca#on?
33
34 Où partent les pa#ents? Unité de cardiologie, IC comme diagnos8c principal DesUnaUon: - 31% réa - 31% chir - Méd interne - Néphro, gastro, hépato % 13 3% 1 0% 52 12% 21 5% 47 11% mutation MCO transfert MCO transfert SSR domicile SHMS décès
35 passage de relais/ transi#on SSR / Réadapta#on cardiaque Titra#on Exercice physique / éduca#on Consulta#on précoce médecin généraliste (8 j) / cardiologue (30 j) consulta#on hospitalière précoce / «HF team» ETP «Réseaux de soins» PRADO Télémédecine / télésurveillance
36
37 Objec#fs Fixer des tarifs préfigurateurs Cibler des pa#ents à haut risque d hospitalisa#ons stabiliser la maladie améliorer la qualité et l efficience des soins améliorer la qualité de vie des pa#ents
38 Quels pa#ents? Hospitalisa#ons au cours des 30 derniers jours avec diagnos#c principal sur le CRH ou codage CIM 10 (I500/501/502/509) Hospitalisa#on au cours des 12 derniers mois et stade NYHA > 2 et BNP > 100 pg/ml ou NT probnp > 1000 pg/ml Pa#ent à domicile ou dans une structure médico- sociale
39 Pa#ents non éligibles
40 Quelles sont les presta#ons? Télésurveillance médicale Presta#on d accompagnement thérapeu#que Solu#on technique (plateforme)
41 Quels sont les acteurs?
42 Accompagnement thérapeu#que du pa#ent et des ses proches Objec#fs : S impliquer et être acteur dans son parcours de soins Mieux connaître l IC chronique Avoir des réac#ons appropriées Forme présen#elle ou à distance (tel ) 3 séances dans les 6 mois Par qui Professionnel de santé (#tulaire d un DU ETP) Médecin avec forma#on de 40 H
43 Solu#on technique Mesure quo#dienne du poids Ques#onnaire sur les symptômes Algorithme perme ant de générer des alertes soit totalement automa#sé sans filtre soit contrôlé par un IDE
44
45 Conclusion L op#misa#on thérapeu#que dans l IC reste un vrai challenge. La ges#on des traitements médicamenteux est devenue complexe L améliora#on de la coordina#on des soins est le 2e challenge et passera sans doute par des
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