TỐI ƯU HOÁ ĐIỀU TRỊ SUY TIM MẠN PGS. TS. CHÂU NGỌC HOA ĐHYD TPHCM

TỐI ƯU HOÁ ĐIỀU TRỊ SUY TIM MẠN PGS. TS. CHÂU NGỌC HOA ĐHYD TPHCM

Signed by HFA / ESC/ HFSA/ ACC/ AHA

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3 In the year 2016, by applying all evidence-based discoveries, heart failure is becoming a preventable and treatable disease. www.escardio.org/guidelines

Objectives in the management of heart failure Improve clinical status Improve functional capacity and quality of life Prevent hospital readmission Reduce mortality

3 key points to optimize treatment of a patient with chronic heart failure PATIENT S JOURNEY RIGHT TIMING RIGHT ACTION

Heart failure patients suffer from recurrent hospitalization With each hospitalization, there is likely myocardial and renal damage which contributes to progressive left ventricular or renal dysfunction, leading to an inevitable downward spiral. 1 1. Gheorghiade M et al. Am J Cardiol. 2005;96:11-17.

Patients are stable by discharge It is important to consider that once hospitalized heart failure patients are stabilized by discharge, the majority of them should be considered to be in a chronic heart failure state at a significantly high risk for adverse outcomes. 1 1. Gheorghiade M et al. Recognizing hospitalized heart failure as an entity and developing new therapies to improve outcomes. Ac ademics, clinicians, industry s, regulators, and payers perspectives. Heart Failure Clin. 2013.9;285-290.

Post-discharge, the prognosis is poor Hospitalized heart failure is associated with unacceptable high postdischarge mortality and rehospitalization rate. 1 1. Gheorghiade M et al. Recognizing hospitalized heart failure as an entity and developing new therapies to improve outcomes. Ac ademics, clinicians, industry s, regulators, and payers perspectives. Heart Failure Clin. 2013.9;285-290.

Mortality is particularly high in the early phase after hospitalization All-cause mortality after discharge for HF is high during the 1 st month 1 Time after discharge from hospital (months) 1. Marti NC et al.timing and duration of interventions in clinical trials for patients with hospitalized heart failure. Circ Heart Fail. 2013;6:1095-1101. - Changes in risk profile after hospitalization. Hazard ratio of all-cause mortality after discharge from hospital for first hospitalization.

Rehospitalization is particularly high in the early phase after hospitalization: 1 out of 2 patients rehospitalized within 2 months EVEREST Timing of major causes of first hospitalization 1 [2159 patients] 1. O Connor CM et al. Causes of death and rehospitalization in patients hospitalized with worsening heart failure and reduce left ventricular ejection fraction: results from efficacy of vasopressin antagonism in heart failure outcome stuy with tolvaptan (EVEREST) program. Am Heart J. 2010;159:841-849.e1.

The high risk in the weeks to months post-discharge may be viewed as the vulnerable phase The post-discharge period is described as an acquired, transient condition of generalized risk or a period of vulnerability. 1 Comprehensive strategies should focus on factors during hospitalization and also during the early recovery period soon after discharge to target stressors that probably contribute to the vulnerability of patients. 1,2 1. Krumholz HM. Post-hospital Syndrome An acquired, Transient Condition of Generalized Risk. NEJM. 2013;368;2 2. Marti NC et al. Timing and duration of interventions in clinical trials for patients with hospitalized heart failure. Circ Heart Fail. 2013;6:1095-1101.

Post-discharge follow-up & survival Death (% of patients) A review of post-discharge assessment (30 days) in more than 10 500 patients from the National Ambulatory Care Reporting System (Canada) 1 1. Metra M et al. Postdischarge assessment after a heart failure hospitalization: the next step forward. Circulation. 2010;122:1782-1785..

Hospitalization is the key moment to optimize treatment to prevent post-discharge mortality and rehospitalization Prevention of adverse outcomes in hospitalized HF patients relies on preventing HF progression by: 1 initiating and titrating evidence-based therapy ensuring continued adherence to that therapy preventing and treating patient comorbidities 1. Psotka MA, Teerlink JR. Strategies to Prevent Postdischarge Adverse Events Among Hospitalized Patients with Heart Failure. Heart Failure Clin. 2013;9:303-320.

Hospitalization is the key moment to optimize treatment 2013 ACCF/ AHA guidelines for HF Recommendations for hospital discharge 1 1. Yancy C 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.

6 Therapeutic algorithm for a patient with symptomatic HFrEF www.escardio.org/guidelines

Survival (%) Elevated heart rate at hospital discharge predicts one-year mortality (OFICA) 41% increase in one-year mortality 1 P = 0.01 N=1658 (170 hospitals); Mean HR at discharge:71 bpm; 1 year mortality: 33% Time (days) 1. Logeart D et al. Raised heart rate at discharge after acute heart failure is an independent predictor of one-year mortality. Eur Heart J. 2012;33(Abst Suppl):485. [ABSTRACT]

HR Reduction as a Therapeutic Target Reduce myocardial oxygen consumption Improve contractile performance Improve diastolic filling Reduce risk of VF and sudden death Promote reverse remodeling BUT Beta-blockers remain underutilized and underdosed in clinical practice (and in trials) Kitai et al., Curr Treat Options Cardio 2016;18:13

Underutilization of Beta-Blockers Gheorghiade et al, Cong Heart Fail 2012;18:9

Practical guidance on the use of beta-blockers in patients with heart failure 23

Optimization of treatment before discharge Pharmacological treatment in CHF recommended in the 2016 ESC guidelines 1 1. McMurray J et al. European Society of Cardiology Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. Eur Heart J. 2012;33:1787-1847..

LVEF, % BNP, pg/ml ETHIC-AHF: effects of the early co-administration of ivabradine and beta-blockers in patients with heart failure 46 44 42 40 600 400 P=0.02 38 36 34 P=0.039 200 0 Hidalgo FJ, et al. Int J Cardiol (2016).

However, Use Declined SOLVD (1991): 66% US Carvedilol (1996): 90% RALES (1999): 73% CHARM-Alternative (2003): 45% RAFT (2010): 35% EMPHASIS (2011): 27% over the subsequent decades in part due to lack of effect on death and downgrade in guideline recommendations

2016 ESC GUIDELINES

Recommendations for initial management of a rapid ventricular rate in patients with heart failure and atrial fibrillation in the acute or chronic setting

Guidelines that aren t implemented don t work

3 key points to optimize treatment of a patient with chronic heart failure PATIENT S JOURNEY RIGHT TIMING RIGHT ACTION