Chẩn đoán và điều trị suy tim có gì mới trong năm 2015-2016

2016 ESC Guideline for the diagnosis and treatment of acute and chronic heart failure... 2016 ESC Guideline for the diagnosis and treatment of acute and chronic heart... 2016 ESC Guidel

Thạch Bệnh viện Tim Tâm Đức

Phân loại suy tim

>40% Nguoi ta nhjn thay c6 mot so it benh nhan suy tim PSTM bao ton ma

truce d6 c6 PSTM gi am Nhiing benh nhan nay c6 PSTM cai thien

hoacb6i phuc c6 th~ c6 d~c di€m lam sang khac bi~t voi benh nhan suy tim

2 Suy rim voi

PSTMbaot6n

> 50% Con goi la su y t m t am t ruong C6 v ii t i eu chuan

d~ dinh nghia suy tim PSTM bao t6n Chin do an suy tim tam tnrong la

mot thu thach bci vi phin 16n la chin dean loai trir nhung nguyen

nhan khong do tim khac gay trieu clnmg gi6ng suy tim Din nay, nhimg

phuong

phap diSu tri hieu qua chua dugc xac nhjn

hoac a nh 6 m trung gian D ~c diem

gioi han 49% lam sang, diSu tri va du hiu nrong t11 nhu benh nhan suy tim PSTM bao

Nguyên nhân suy tim tâm thu mạn tính (1)

1.

•

•

Bệnh động mạch vành Nhồi máu cơ tim*

Thiếu máu cục bộ cơ tim*

4 Bệnh cơ tim dãn nở không TMCB

Nguyên nhân suy tim

5 Rối loạn nhịp và tần số tim

7 Các tình trạng cung lượng cao

8 Rối loạn chuyển hóa

• Cường giáp

• Rối loạn dinh dưỡng (Td: beriberi)

9 Nhu cầu dòng máu thái quá (excessive blood flow requinement)

Nguyên nhân suy tim tâm

PATIENT WITH SUSPECTED HF'

d iu retics Orthopnoea I paroxysma l

2 P hys i cal e xamina t on : fules

Bilatera l ankle oedema Heart murmur Jugular venous d i latation Laterally displaced/broa d ened apical b ea t

o f n a triu re ti c

p eptides not routinely d on e in

cl i nical practic e

TL: Ponikowski P 2016 ESC Guideline for

the diagnosis and treatment of acute and

chronic heart failure Eur H J, May 20, 2016

6

Tiêu chuẩn chẩn đoán suy tim

PXTM bảo tồn

1 Có triệu chứng cơ năng và/hoặc

của suy tim PXTM bảo tồn (LVEF ≥ 50%)

thực thể

2.

3 Tăng Natriuretic Peptide (BNP > 35

pg/ml và/hoặc NT-proBNP > 125 pg/ml) Chứng cứ biến đổi cấu trúc và chức năng của suy tim

4.

TL: Ponikowski P 2016 ESC Guideline for the diagnosis and treatment of acute and chronic heart

Khảo sát di truyền bệnh nhân

TL: Ponikowski P 2016 ESC Guideline for the diagnosis and treatment of acute and chronic heart

Mục tiêu điều trị suy tim

0 Add M R anta 1 on l s t'-"

(up-tltr.tte to maximum tolented evidence- ba1e d dose)

.

0

u

.

0 Q.

E

"

'

TL: Ponikowski P 2016 ESC Guideline for the

diagnosis and treatment of acute and chronic

heart failure Eur H J, May 20, 2016

l P at i e n t w i th s y mp tomat i c" HFrEF "

• Class I

T h e rapy with ACE - ' and beta-b l ocke r

(Up-titrateto nwtimum tolented evldence.based

-" E ' ., ;.:.;

l

or LVAD, or heart transplantation

C ons i der reducing diuretic 1d0ose

U s i n oprl' 2 5- S Oo.d. 2 0- JS o.d.

Ramtpr i 2 5 o.d 1 0 o d.

T ra n dobp ri l' 0 5 o.d. • o.d.

B eta - bloc k ers

S isop ro l ol 1 25 o.d 1 0 o.d.

Aa • an pot en si n ·con , e rt1 n1 en zyme ANS • ~ receptor

blocbr

ARNI • an, l o te ns l nre ~l o r neprilysin Wtlbitor: bJ d • bu fl de ~ daJy):

MR.A • rri ne r aloc.ortlcoi d r eceptor anu,orist: o.d • c,rrr,e n <M (once duly):

tJ d • ter I n d i e (three ti mes a da y )

"'Indica tes :,n A C E - I w h e re th e dOSMlt tarJe l Is c:feri,,,ed from post ~

ri :,rcoon tria ls

"'lncl lc.ates «ua s w h r e a hl &htt doi e h JS been shc:M.l to

l't'O.JCe n bldi.yf mon:allty c om pa redw i th a l o wer dose oi the same dNz buE

there is no S\bstanti.,,e random ized pl ac ebo- co n tro ll e d trial and the opdmun

dose k mcen:ain.

., ndlc.i teS a uenm e n t no t sho w to reduc e c:wdiov.l:s-cubr or d-ouse mc:wtMy

in

paoen ts w ith h e lt't fa i ure ( o r s ho wn to be

non-«'lferiot to a trearnent tNl does ).

•A maidm u m dos e of SO me twice d ll ty an be aonristen!'d to pments ~

MRAs

ARN ISacubknllv.alsan an

'4 9/SI bld. 97/IOJ

b Ld.

TL: Ponikowski P 2016 ESC Guideline for the

diagnosis and treatment of acute and chronic heart

failure Eur H J, May 20, 2016

If-channel blocker

lvabnd i ne 5 bl d. 7 5 lud

eart failure Eur H

w e ight: excess i ve d s s may cause renal i mpairment and o t oto x i city.

l>oo not u se thiazid es i f es tim ated glo m e rular filtration rate < 30 m U i n/ 1 7 3

m 2 ,

except when prescribed s yn ergis t ically with loop d iu retics

<lndapamide is a non -t h i az i de s ulf onam i de

dA m era l ocortico i d a nta g on i st (MRA ) i e spironolactonelep l eren one i s

nic heart failure Eur H J, May 20, 2016

Các thuốc khác được sử dụng điều trị suy tim PXTM giảm kèm NYHA II- IV (1)

TL: Ponikowski P 2016 ESC Guideline for the diagnosis and treatment of acute and chr

R ecom m en d ati o ns Cl ass •

L eve l b R e f '

D i ure tics

Diuretics are recommended i n order to ~ symptoms and exercise capacity i n patients with signs

1 79

1 78 ,

1 79

D i ure ti cs s h ou l d be co n s i dered to reduce the ri sk of HF hosp i tal i zation i n patients w i th s i gns and/or

A ngiotens i n receptor nep rily s i n i n i b it or

Saatbitri/valsanan is reconvnended as a replacement for anAa -l to further reduce the risk of HF

hospitalizatio n and death i n

amlxJatory patients with HFrEF who remain symptomatic despite optimal treatment with an ACE-1 ,a

16

2

nic heart failure Eur H J, May 20, 2016

Các thuốc khác được sử dụng điều trị suy tim PXTM giảm kèm NYHA II- IV (2)

TL: Ponikowski P 2016 ESC Guideline for the diagnosis and treatment of acute and chr

An ARB may be considered to reduce the risk of HF hospitalization and death in patients w h o are

I f-channe l i nhib i tor

lva b radi n e shou l d be cons i dered to reduce the ri sk of H F hospita l ization an d ca r dio v ascu l a r deat h in

s y mptomatic patients

w ith LVE F ~35 %, i n s i nus rhythm and a res ti ng heart rate ~ 7 0 bp m desp i te tre a tment w i th a n ev i

dence-based dose of beta·

b l o c k e r (or maxim u m to l era t ed dose below that ), A CE-1 ( or AR B) , a n d a n MRA ( or ARB)

lv a br a din e s h ou l d be cons i dered to reduce the risk of H F hospitalization an d cardio va sc u l ar d eat h in

s ym ptomatic patients with

LVEF ~ 35 %, in sinus mythm and a resting heart rate ~70 bpm who are un a ble to t o l e ra te o r hav e

con t ra - ind icatio n s for a

beta-b l ock er Pati ents s h ou l d also receive an A CE-I (or ARB ) and an MRA ( o r ARB ).

ARB

A n ARB i s recommended to reduce the risk of HF hospitalization and

cardiovas c u l ar death in sympt to l erate an ACE-I (patients should a l so receive a

beta-blocker and an MRA)

An ARB may be considered to reduce the risk of HF hospitalization and death in

patients w h o are wi h a beta-b l ocker who are unable to tolerate an MRA.

I

llb

1 82

ailure Eur H

J

Các thuốc khác được sử dụng điều trị suy tim

PXTM giảm kèm NYHA II- IV (3)

ACEI = angiotensin-converting enzyme i nhibito r ARB= ang i otens in receptor blocke r BNP= 8-type natriuretic peptide: bpm = beats

per minute : HF=

heart fa i lure ;

HFrEF =

h eart failure with reduced ejection fract i o : LVEF = l eft vent r icular ejection fract i on: MRA = m i neralocorticoid recepto r antagon i st NT · proBNP =

N-tenminal pro-B type

natriuretic peptide : NYHA = New York Heart Association: PUFA = po l yunsaturated fatty acid OMT = opt i ma l medica l therapy (for HFrEF this mostly comprises an ACEI or sacubitriVva l sartan, a beta-blocker and an MRA }.

'Class or

recommendation b l evel

of evidence.

'Reference(s} supporting recommendations

dPatient should have e l evated natri u retic peptides (plasma BNP :::: 150 pg/ml or plasma NT · proBNP :::: 600 pg/ml or if HF hospitalization w i thin the last

12 months pb.sma BNP

:::: 100 pg/ml or plasma NT-proBNP :::; 400 pg/ml) and able to tolerate enalapri l 10 mg bJd.

•Applies on l y to preparation studied in cited trial

Hydraluine and isosorbide dinitrate C l ass • L e ve l b R e f '

Hydralazine and i sosorb i de dinitrate should be considered in se l f- i dent i fied black patients with LVEF ~5% or

patients with HFrEF who can tolerate neither an ACE-I

nor an ARB (or they are contra ~ n<focaced) co reduce the ri sk or death

4

O the r t reatments w ith l e ss - c rtain be nefits

D i goxin

Digox i n may be cons i dered i n symptomatk patients i n s i nus rhyth m despite treatment with an ACE-I ( or

ARB ) a beta-blocker and an M RA to reduce the risk or hosp i talization ( both a ll -cause and HF-hospitalizations) llb 18

5

N · l PUFA

An n-J PUFA' preparation may be cons i dered i n symptomatic HF patients to reduce the ri sk or cardiovascular

Recommendations Ref'

Thiazolidined ones (glitazones) are

not recommended n patients

with

HF, as they increase the risk of

HF worsening and HF hospit-al zation

NSAIDs or COX-2 inhibitors are

not recommended n patients with

211 -

HF, as they increase the risk of HF

213

worsening and HF hospit-alization

Diltiazem or verapamil are not

recommended in patients

withHFrEF as they increase the

214

risk of HF worsening and HF

hospitalizatio

n

The add tion of an ARB (or renin

inhibitor) to the combination

of an ACE-I and an MRA is not

A CEI = angiotensin-conv ertin g e n zy m e i nh i b i to r: A RB = angioten s i n r ecep t o r

bl ock er: CO X - 2 inhibi tor = cycloo x yge n ase - 2 i nhibitor: HF = heart fail u re :

H FrEF = heart fa i lure w i th re d uce d e j ectio n fraction : M RA =

minera l oco rtico i d

receptor antagon i st: N SA I Ds = non- steroida l anti-inflammatory

drogs

' C l ass or recommendation

"Level or evidence.

• R ererence ( s) supporting rec omm e nd a t o ns

TL: Ponikowski P 2016 ESC Guideline for the di

i

i

ii

,

i

i l

nic heart failure Eu

TL: Ponikowski P 2016 ESC Guideline for the diagnosis and treatment of acute and chro r H J, May 20,

An ICD is recommended to reduce the risk of s u dden dea th and all-cause mortality in pat ents who have

recovered from a ventricular arrhythmia caus i ng haemodynamic i nstabi ity , and who are expected to survive for>

I year with good functiona l status

year with good funct ion al stat us, and th e y have :

• I HD ( u less the y h ave ha d an M l i n the prior 40 day s - s ee b e l o w )

• DCM

Điều trị tái đồng bộ tim (CRT) (1)

Recommendations C lass •

Ref' CRT is recommended for symptomatic patients with HF n sinus rhythm with a QRS duration ~ 50 msec and LBBB QRS m or p hology and with LVE F 535% despite O MT i n order to i mprove sy mp t o ms a nd re d u ce mo r bi d ty a nd morta li ty I C R T s h ou d b e cons i dered for sympto ma tic patients wi th H F in s i nus rhyth m w th a QRS d u ra ti o n ~ 1 5 0 msec an d n o n - LBBB QR S morphology and wi th LV EF 535 % despite O MT in orde r to m pro v e s y m p toms a nd r educe m orb d ty an d m orta li ty Ila C R T s r ecommended for symptomatic patients with H F n sinus r hythm with a QR S d u ratio n of 1 30- 49 ms ec and LBBB Q R S m or p hology a nd with LV EF 535% despite O MT i n order to improve s y mp toms a n d re duce mo r bi d ty an d m o rta li ty I CR T ~ be cons i dered for symptomatic pa ti ents with H F i n s nu s rhyth m w i h a QRS d u ra tio n o f 30-149 msec and non - L BBB Q R S morphology and w ith LV EF 535 % despite OMT in orde r to m pro v e sy mp toms a n d reduce m orb d ty an d m orta li ty ll b CRT rather than RV pacing is reconvnended for patients with HFrEF regardlessof NYHA class who have an ind cation for ventricular pacingand high degree AV block in order to reduce morbidity.Thisincludes patients with AF (see Section 0 1) I 18 TL: Ponikowski P 2016 ESC Guideline for the diagnosis and treatment of acute and chronic heart failure Eur H J, May 20, 2016 i

1

i l

i

i

i i

i

i

1

i i

1

i

i i i

1

nic heart failure Eur H J, May 20, 2016

Điều trị tái đồng bộ tim (CRT) (2)

redece morbidity and mortal ty, if they are in AF and have a QRS duration~ 130 msec

provide<! a stra tegy to ensure bi-ventricular

and who have a high proportion of RV pacing may be considered for upgrade to

CRtThis does not app~ to patients with stable HF

AF = atrial fi bril lation ; A V= atri o- ventricular: CRT= card i ac r esynchro ni z t o n the ra p y:HF= heart fai l ure : HFrE F = heart fa ilu re

imp l antable car d l o verter - defibrillator.LBBB = l eh bund l e branch b l ock; L VEF = leh ventricular ejection fraction ; NY HA = N e w

therapy : Q RS = Q Ran d S waves ( combination of three of the gr ap hi ca l de fle ct ions) ; RV = righ t ventricular

' C lass or

rec o mmendation

'Referenc e( s ) supportin g r ecommendations.

'\Jse ju d ge me n t f or pa ti e nts with end - stage HF who m igh t be manage d cons e rv a ti vely rather than with treatments to i mp rov e

s ym pto m s o r prognos i s.

9

TL: Ponikowski P 2016 ESC Guideline for the diagnosis and treatment of acute and chr

CRT should be considered for patients with LVEF ~5% in NYHA Class III-N1 despite

OMT in order to improve symptoms and

capture is in place or the patient is expected to return to sinus rhythm

Patients with HFrEF who have receried a conventional pacemaker or an ICD and

subsequently deYelop worsening HF despite OMT

27

5,

27Pr2

81282266,

28

3-285

Điều trị suy tim PXTM bảo tồn

T/C cơ năng, thực thể

20

May

20, 2016

failure Eur H.

Khuyến cáo điều trị suy tim PXTM bảo tồn (HFpEF)

(HFmrEF)

và suy tim PXTM trung gian

with preserved eiecuon f raction

"Level of evidence

TL: Ponikowski P 2016 ESC Guideline for the diagnosis and treatment of acute and chronic

heart

J,

Recommendations Class• level • Ref'

it is recommended to screen

Hiệu quả trên tử vong của điều trị suy

tim PXTM bảo tồn

beta, đối kháng aldosterone: không nghiên cứu chứng minh giảm tử vong

vong và nhập viện HFrEF, HFpEF hoặc HFmrEF*

TL: * Van Veldhuisen DJ et al J Am Coll Cardiol 2009, 53: 2150-2158

* Flather MD et al Eur Heart J 2005: 26: 215-225

22

Điều trị loạn nhịp tim trên bệnh nhân suy tim

23

heart failure Eur H J, May 20, 2016

Khuyến cáo xử trí tần số thất nhanh trên b/n suy tim kèm RN trong bệnh cảnh cấp hay mạn (1)

Fo r p at i e nts i n N Y HA C l ass I V ,

i n

a dd i tion to tr eat me nt f or AH F , an

intr ave n ou s b o l u s o f a m i o d a rone

or , i n digo x i n -n a i" ve p ati e n ts , a n

in trave n ous bo l us o f dig oxin s h ul d

v e ntric u l a r r ate

- NYHA IV: - Sốc điện

- Amiodarone

- DigoxinNYHA I- III: - Chẹn beta

- Digoxin

- Huỷ nút N-T-

TL: Ponikowski P 2016 ESC Guideline for the diagnosis and treatment of acute and chronic

R e co m m e nd at i on s Clas s• L ev e l b R e f <

Urgent electrica l card i oversion i s recommended if A F i s though t to

be contributing to the p a t ent ' s

h a emod y nam i c compromise in order to improve the pat i ent clinical