CẬP NHẬT điều TRỊ SUY TIM mạn NEW2014

CẬP NHẬT ĐIỀU TRỊ SUY TIM MẠN PGS.. Medical Digoxin Diuretics ACE I ARB Mineralocorticoid Receptor Antagonists Beta Blockers Ivabradine ARB/NEP inhibitor A PARADIGM Shift... Beta Bl

CẬP NHẬT ĐIỀU TRỊ SUY TIM MẠN

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• - THAY ĐỔI VỀ TIÊN LƯỢNG SUY TIM

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• NHỊP TIM TỐI ƯU

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Medical

Digoxin Diuretics

ACE I ARB Mineralocorticoid Receptor

Antagonists Beta Blockers

Ivabradine

ARB/NEP inhibitor

A PARADIGM Shift

Beta Blockers

James Black FRS

Lancet 18 th August 1962

British Heart Journal 1980

Beneficial effects of long-term beta-blockade in congestive

Cardiomyopathy

K Swedberg, A Hjalmarson, F Waagstein, Wallentin

Twenty-eight patients with heart failure caused by congestive

Cardiomyopathy…., were treated with beta-blocking agents for 6 to 62

months

During follow-up, 10 patients died, most of them suddenly The mortality

was lower than expected in this severely ill group of patients

…beta-receptor blockade should be added to conventional treatment with digitalis and diuretics in all patients with severe myocardial

Failure caused by congestive cardiomyopathy

Chronology of ACE- I and Beta-Blocker Studies

 Funck-Brentano C Eur Heart J Suppl 2006;8:C19-C27

 © The European Society of Cardiology 2006 All rights reserved For Permissions, please e-mail:

 journals.permissions@oxfordjournals.org

 15

SENIORS – KẾT QUẢ

Tử vong do mọi nguyên nhân và nhập viện do tim mạch

Flather MD, et al Eur Heart J 2005;26:215-25

Pharmacological therapy for CHF patients

20 NĂM SAU CHẸN RAAS VÀ CHẸN BÊTA

KHÁI NIỆM ĐIỀU TRỊ VÀ ĐIỀU TRỊ MỚI

Ivabradine (SHIFT)

Công nhận sự hoạt hóa hệ TK- thể dịch

ACE-Inhibitors or ARBs (1)

• An increase in creatinine of up to 50% above

baseline, or eGFR 20- 25 mL/min/1.73 m2

1 concomitant nephrotoxic drugs (e.g NSAIDs)

2 other potassium supplements or retaining agents

(triamterene, amiloride)

3 if no signs of congestion, reducing the dose of diuretic

ACE-Inhibitors or ARBs (2)

• If adjustment of concomitant medications is not

sufficient, the dose of the ACE inhibitor (or ARB)

should be halved and blood chemistry re-checked within

1-2 weeks

• If there is still an unsatisfactory response, specialist

advice should be sought

• If potassium rises to >5.5 mmol/L or creatinine

>100% or eGFR <20 mL/min/1.73 m2, the ACE

inhibitor (or ARB) should be stopped

• Blood chemistry should be monitored frequently and

serially until potassium and creatinine have plateaued

Mineralocorticoid receptor antagonists

• The risk of hyperkalaemia and renal dysfunction

increases when an MRA is added to an ACE

inhibitor or an ARB

• The triple combination of an ACE inhibitors, ARB

and MRA is NOT recommended

• If K+ rises above 5.5 mmol/L or creatinine rises to

>2.5 mg/dL or eGFR <30 mL/min/1.73 m2, halve

dose and monitor blood chemistry closely

• If K+ rises to >6.0 mmol/L or creatinine to >3.5

mg/dL or eGFR <20 mL/min/1.73 m2, stop MRA

immediately and seek specialist advice Eur Heart J 2012;33:1787–1847

DrugClass Elimination DoseAdjustments