TÌNH HÌNH SUY TIM & CẬP NHẬT CHÂN ĐOÁN - ĐIỀU TRỊ THEO ESC & ACC 2016

Transcription

1 TÌNH HÌNH SUY TIM & CẬP NHẬT CHÂN ĐOÁN - ĐIỀU TRỊ THEO ESC & ACC 2016 UPDATE ON SITUATION, DIAGNOSIS & MANAGEMENT OF HEART FAILURE FOLLOWING THE 2016 ESC & ACC GUIDELINES HUYNH VĂN MINH, FACC, FAsCC HUE UNIVERSITY OF MEDICINE & PHARMACY HUE MEDICAL UNIVERSITY

2 ĐẶT VẤN ĐỀ Introduction Around 1-2% of adults in developed countries have heart failure. During one year, 17% of hospitalised and 7% of stable/ambulatory heart failure patients will die, primarily from sudden death and worsening heart failure. "Heart failure is becoming a preventable and treatable disease. Implementing the guidelines published today will give patients the best chance of a positive outcome. (Ponikowski) Medscape, July 2016

3 10 THÔNG TIN CẦN HÀNH ĐỘNG CỦA SUY TIM

4 GÁNH NẶNG SUY TIM VÙNG ĐÔNG NAM Á GLOBAL BURDEN OF HEART FAILURE IN SOUTH EAST ASIA

5 TỈ LỆ SUY TIM TRÊN TOÀN THẾ GIỚI PREVALENCE OF HEART FAILURE IN THE WORLD, 2014

6 SỐ CA MỚI MẮC / NĂM SUY TIM TRÊN CÁC VÙNG CỦA TCYTTG Incidence (millions) by WHO Region Region Africa America Mediterranean Europe Southeast Asia West Pacific World New cases in millions / year 0.5 M 0.8 M 0.4 M 1.3 M 1.4 M 1.3 M 5.7 M Incidence of congestive heart failure due to rheumatic heart disease, hypertensive heart disease, ischemic heart disease or inflammatory heart diseases GBD - WHO 2004

7 CẢNH QUAN ĐẦU THẾ KỶ 21: CÒN THIẾU DỮ LiỆU CỦA CÁC QUỐC GIA THU NHẬP THẤP & TRUNG BÌNH

8 Significant variations in: Culture Lifestyle and diet Healthcare system Income Population index Southeast Asia

9 SUY TIM Ở CÁC NƯỚC THU NHẬP THẤP & TRUNG BÌNH

10 TẦN SUẤT & TỈ LỆ SUY TIM Ở CÁC NƯỚC ĐÔNG NAM Á Prevalence and Incidence of Heart Failure Country Prevalence Incidence South Korea /1000 Japan % -- Hong Kong 0.5% 3.4/1000 China Taiwan 5.5% 2.7/1000 Thailand Philippines Indonesia Malaysia 6.7% -- Singapore Australia % 30,000 /year Eugenio B. Reyes, M.D., University of Philippine, College of Medicine, The Burden of Heart Failure in SEA, 2010

11 How about in Vietnam? In Vietnam, there is no available data on the prevalence of heart failure of the population. Using the worldwide prevalence (0,4-2%) to apply for the population of 90 million people, it is estimated to have from to 1,8 million people living with chronic heart failure in Vietnam [1].

12 NGUYÊN NHÂN SUY TIM Ở CÁC NƯỚC ĐÔNG NAM Á Etiology of Heart Failure Country Hypertension IHD Valvular South Korea 20 % 42 % 28 % Japan 14 % 25.4% 26.4% Hong Kong 37 % 31 % 15 % China 12.4% 45 % -- Thailand 12 % 47 % 19 % Philippines 5.7 % 52 % 20 % Indonesia 54.4% 50 % -- Malaysia 18.6% 49.5% 4.1% Singapore 20.2% 66.5% 3.5% Eugenio B. Reyes, M.D., University of Philippine, College of Medicine, The Burden of Heart Failure in SEA, 2010

13 How about in Vietnam? 17,6% 10,1% 5,7% 4,4% 39,6% Valvular heart disease Hypertension Coronary heart disease 22,6% Cardiomyopathy Arrythmias Others Mai Van Thuat, Huynh van Minh, Some aspects of hospitalised HF patients n Hue University Hospital, 2016

14 TẦN SUẤT CÁC YTNC SUY TIM Ở ĐÔNG NAM Á Prevalence of Risk factors for Heart Failure Country HTN DM MI/CAD Arrhythmia Age > 65 South Korea 20 % 21 % 90 % Japan 47 % 19 % 39 % 66 % Hong Kong 36 % 21 % 60 % China 20 % 24 % Thailand 65 % 47 % 45 % 24 % 24 % Philippines 64 % 41 % 37 % 4% 53 % Indonesia 54.8% 31.2% 23.3% 14.6% 64.5% Malaysia 49.5% 28.9% 25.8% 4.1% 69 % Singapore 67.6% 50.3% 46.8% 16.5% 67.6% Eugenio B. Reyes, M.D., University of Philippine, College of Medicine, The Burden of Heart Failure in SEA, 2010

15 Percentage of previous history How about in Vietnam? ,4% 39,6% 36,5% 27,0% 27,0% 11,3% 24,5% 4,4% 10,1% 0,0% Mai Van Thuat, Huynh van Minh, Some aspects of hospitalised HF patients n Hue University Hospital, 2016

16 THUỐC ST Ở CÁC NƯỚC THU NHẬP THẤP & TRUNG BÌNH

17 How about in Vietnam? ,8% 78,6% 74,8% ,1% 36,5% 32,1% ,9% 6,3% 1,3% 1,3% 0 Mai Van Thuat, Huynh van Minh, Some aspects of hospitalised HF patients n Hue University Hospital, 2016

18 LÂM SÀNG SUY TIM Ở CÁC NƯỚC ĐÔNG NAM Á CLINICAL ASPECTS OF HF IN SEA

19 How about in Vietnam? Echo parameter EF (%) Value Category of HF n % 50 Preserved EF , Bordeline EF 36 22,6 40 Reduced EF 18 11,3 Mai Van Thuat, Huynh van Minh, Some aspects of hospitalised HF patients n Hue University Hospital, 2016

20 CẬP NHẬT CHẨN ĐOÁN & ĐIỀU TRỊ SUY TIM THEO KHUYẾN CÁO ACCF & ESC 2016 UPDATE ON DIAGNOSIS & TREATMENT OF 2016 HF ACCF & ESC GUIDELINES

21 CẢNH QUAN ĐẦU THẾ KỶ 21: SUY TIM CÓ THỂ ĐIỀU TRỊ & DỰ PHÒNG

22 CÁC NHÓM THUỐC GiẢM TỬ VONG TRONG SUY TIM EF GiẢM

23 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.

24 1. ĐỊNH DANH MỚI SUY TIM New Definition of Heart Failure 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.

25 Definition of Heart Failure 2013 Classification I. Heart Failure with Reduced Ejection Fraction (HFrEF) Ejection Fraction Description 40% Also referred to as systolic HF. Randomized clinical trials have mainly enrolled patients with HFrEF and it is only in these patients that efficacious therapies have been demonstrated to date. II. Heart Failure with Preserved Ejection Fraction (HFpEF) 50% Also referred to as diastolic HF. Several different criteria have been used to further define HFpEF. The diagnosis of HFpEF is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF. To date, efficacious therapies have not been identified. a. HFpEF, Borderline 41% to 49% These patients fall into a borderline or intermediate group. Their characteristics, treatment patterns, and outcomes appear similar to those of patient with HFpEF. b. HFpEF, Improved >40% It has been recognized that a subset of patients with HFpEF previously had HFrEF. These patients with improvement or recovery in EF may be clinically distinct from those with persistently preserved or reduced EF. Further research is needed to better characterize these patients ACCF/AHA Guideline for the Management of Heart Failure

26 Definition of Heart Failure ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.

27 2. PHÁC ĐỒ CHẨN ĐOÁN MỚI New algorithm of Heart Failure

28 PHÁC ĐỒ CHẨN ĐOÁN SUY TIM ESC 2012 Diagnostic Flowchart

29 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.

30 3. HAI NHÓM THUỐC ĐIỀU TRỊ SUY TIM MỚI Two new HF drugs

31 Pharmacologic Treatment for Stage C HFrEF HFrEF Stage C NYHA Class I IV Treatment: Class I, LOE A ACEI or ARB AND Beta Blocker For all volume overload, NYHA class II-IV patients For persistently symptomatic African Americans, NYHA class III-IV For NYHA class II-IV patients. Provided estimated creatinine >30 ml/min and K+ <5.0 meq/dl Add Add Add Class I, LOE C Loop Diuretics Class I, LOE A Hydral-Nitrates Class I, LOE A Aldosterone Antagonist 2013 ACCF/AHA Guideline for the Management of Heart Failure

32

33 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.

34

35 Ivabradine 2013 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.

36

37 3a. Nhóm ARNI tác dụng như thế nào? Angiotensin Receptor Neprilysin Inhibitors? 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.

38 CƠ CHẾ TÁC DỤNG CỦA Sacubitril/Valsartan (LCZ 696)

39 PARADIGM-HF Trial design: Participants with NYHA class II-IV and LVEF 40% were randomized to LCZ mg twice daily (n = 4,187) vs. enalapril 10 mg twice daily (n = 4,212). 30 % 15 0 (p < 0.001) CV death or hospitalization for heart failure LCZ mg twice daily Enalapril 10 mg twice daily Results CV death or hospitalization for heart failure: 21.8% of LCZ696 group vs. 26.5% of the enalapril group (p < 0.001) CV death: 13.3% vs. 16.5% (p < 0.001), respectively Hospitalization for HF: 12.8% vs. 15.6% (p < 0.001), respectively Conclusions Among participants with reduced EF and NYHA class II-IV symptoms, the use of LCZ696 was beneficial compared with enalapril LCZ696 was associated with a reduction in CV death or hospitalization for heart failure McMurray JJ, et al. N Engl J Med 2014;371:

40

41

42 3b. Ivabradine tác dụng như thế nào?

43

44

45 4. CHỈ ĐỊNH MỚI CRT Modified Indication for CRT Cardiac resynchronisation therapy (CRT) is now contraindicated in patients with a QRS duration less than 130 msec after the EchoCRT study found it may increase mortality in this group. This is a change from the 120 msec cut-off in the 2012 guidelines. The indications for CRT vary according to the presence or absence of left bundle branch block and QRS duration ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.

46 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.

47 Indications for CRT Therapy Benefit for NYHA class I and II patients has only been shown in CRT-D trials, and while patients may not experience immediate symptomatic benefit, late remodeling may be avoided along with long-term HF consequences. There are no trials that support CRT-pacing (without ICD) in NYHA class I and II patients. Thus, it is anticipated these patients would receive CRT-D unless clinical reasons or personal wishes make CRT-pacing more appropriate. In patients who are NYHA class III and ambulatory class IV, CRT-D may be chosen but clinical reasons and personal wishes may make CRT-pacing appropriate to improve symptoms and quality of life when an ICD is not expected to produce meaningful benefit in survival. Patient with cardiomyopathy on GDMT for >3 mo or on GDMT and >40 d after MI, or with implantation of pacing or defibrillation device for special indications LVEF <35% Evaluate general health status Acceptable noncardiac health Comorbidities and/or frailty limit survival with good functional capacity to <1 y Continue GDMT without implanted device Evaluate NYHA clinical status NYHA class I LVEF 30% QRS 150 ms LBBB pattern Ischemic cardiomyopathy QRS 150 ms Non-LBBB pattern NYHA class II LVEF 35% QRS 150 ms LBBB pattern Sinus rhythm LVEF 35% QRS ms LBBB pattern Sinus rhythm LVEF 35% QRS 150 ms Non-LBBB pattern Sinus rhythm QRS 150 ms Non-LBBB pattern NYHA class III & Ambulatory class IV LVEF 35% QRS 150 ms LBBB pattern Sinus rhythm LVEF 35% QRS ms LBBB pattern Sinus rhythm LVEF 35% QRS 150 ms Non-LBBB pattern Sinus rhythm LVEF 35% QRS ms Non-LBBB pattern Sinus rhythm Special CRT Indications Anticipated to require frequent ventricular pacing (>40%) Atrial fibrillation, if ventricular pacing is required and rate control will result in near 100% ventricular pacing with CRT Colors correspond to the class of recommendations in the ACCF/AHA Table 1.

48 5. DỰ PHÒNG SUY TIM MỚI New HF prevention Novel recommendations to prevent or delay the onset of heart failure and prolong life include: - treatment of hypertension, - statins for patients with or at high risk of coronary artery disease, - and empagliflozin (a sodium-glucose cotransporter 2, or SGLT2 inhibitor) for patients with type 2 diabetes ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.

49

50 IN CONCLUSION 1. Heart failure(hf) is an emerging health issue, not only in developed world but also in South East Asia. 2. Updated recommendation on HF with new medication and intervention will help to improve the survival rate of patients with HF. 3. Vietnam has made great achievements on HF management such as heart transplantation, VSD implantation, developing National HF guideline However, there is still a strong need on epidemiological study and evaluation research on implementation of new methods to prevent and treat HF at different health facilities across the country./.

51 CÁM ƠN SỰ THEO DÕI CỦA QUÍ ĐẠI BIỂU XIN HE N GĂ P LẠI TẠI HÔ I NGHI TIM MẠCH MIÊ N TRUNG LẦN THỨ IX, TUY HÒA, PHÚ YÊN, 14-16/7/2017 THANK YOU FOR YOUR ATTENTION AND SEE YOU AT CENTRAL CONGRESS OF CARDIOLOGY IN 14 th - 16 th JULY 2017, PHU YEN.