Suy tim với chức năng tâm thuthất trái bảo tồnNhững vấn đề còn thách thức

Centers for Medicare and Medicaid Services CMS from January 1, 2005, through December 30, 2009, with 5 years of follow-up through the end of December 2014 HF, heart failure; HFrEF, hear

Suy tim với chức năng tâm thu

thất trái bảo tồn

Những vấn đề còn thách thức

TS.BS Hoàng Văn Sỹ Đại học Y Dược Tp Hồ Chí Minh Khoa Nội Tim mạch BV Chợ Rẫy

TP HCM 13/7/2019

Tần suất suy tim với EF bảo tồn (HFpEF)

In patients with clinical

HFrEF3a

The proportion of incident cases of HFpEF increased from 47.8% in 2000–2003 to 52.3% in 2008–20102

a The GWTG-HF registry was merged with claims from the U.S Centers for Medicare and Medicaid Services (CMS) from January 1,

2005, through December 30, 2009, with 5 years of follow-up through the end of December 2014

HF, heart failure; HFrEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction.

Khoảng ½ bệnh nhân suy tim có triệu chứng là suy suy tim

EF bảo tồn

1 Yancy CW et al Circulation 2013;128:e240-e327; 2 Gerber Y et al JAMA Intern Med 2015;175(6):996-1004; 3 Shah KS et al J Am Coll Cardiol 2017;70(20):2476-2486; 4 Oktay AA et al Curr Heart Fail Rep 2013; 10(4): doi:10.1007/s11897-013-0155-7.

Định nghĩa các loại suy tim theo ESC

Cơ chế bệnh sinh còn chưa rõ ?

Subclinical

LV dysfunction

Years/months Years

HFrEF is also called systolic HF, although patients may also exhibit diastolic abnormalities

HFpEF is also called diastolic HF , although most patients have evidence of both systolic and diastolic dysfunction

Age Smoking Dyslipidemia CAD/MI Hypertension Obesity Diabetes

Systolic dysfunction

Diastolic dysfunction

CAD, coronary artery disease; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; LV, left ventricular; MI, myocardial infarction.

Hypertension and coronary artery disease are major risk factors for

development of heart failure

Suy tim EF bảo tồn là biểu hiện của 1 bệnh ?

1 Krum H, Gilbert RE Lancet 2003;362:147–58; 2 Borlaug BA, Paulus WJ Eur Heart J.2011;32:670–679.

1

Sinh bệnh học của HFpEF Các cơ chế SBH trung ương và ngoại vi

are usually described

according to the most

dominant clinical

characteristics:

• HFpEF subphenotype

with PAH and RV

dysfunction has been

well characterized and

signifies advanced

stage HF

Central Mechanisms

RV Dysfunction

AF and

LA Dysfunction

LV Systolic Stiffening and Dysfunction

LV Diastolic Stiffening and Dysfunction

RV Filling Pressures

Load sensitivity

Exercise tolerance

LV Filling Pressures

Autonomic dysfunction

Coronary and systemic microvascular rarefaction

Pulmonary

Pulmonary venous hypertension

± Impaired diffusion capacity

± ‘Reactive’ arterial hypertension

Peripheral Mechanisms

AF, atrial fibrillation, LA, left atria; LV, left ventricular; RV, right ventricular; HFpEF, heart failure with preserved ejection fraction; PAH, pulmonary arterial hypertension

Zakeri R and Cowie MR Heart 2018;104(5):377-384

Suy tim EF bảo tồn là biểu hiện của nhiều bệnh ?

Kiểu hình lâm sàng và bệnh lý đi kèm

trong HFpEF

The most commonly encountered clinical

phenotypes of HFpEF include hypertension

(identified as the core risk factor), aging, obesity,

pulmonary hypertension, and CAD1,2

These clinical phenotypes further share comorbid

conditions that include atrial fibrillation, anemia,

COPD, frailty, diabetes, obstructive sleep apnea,

and CKD2

• Aging-related comorbid conditions include atrial fibrillation,

anemia, COPD and frailty

obstructive sleep apnea and CKD

Defining clinical phenotypes could be essential for

management of patients with HFpEF leading towards

Frailty

Obstructive sleep apnea

CAD, coronary artery disease, CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; HFpEF, heart failure with preserved ejection fraction; PH, pulmonary hypertension.

1 Yancy CW et al Circulation 2013;128:e240-e327.

2 Samson R et al J Am Heart Assoc 2016;5(1):e002477 doi:10.1161/JAHA.115.002477.

Chẩn đoán HFpEF còn khó khăn ?

2

Kishan S, et al JACC: HEART FAILURE VOL.6,NO.8,2018

Chẩn đoán HFpEF còn khó khăn ?

2

Kishan S, et al JACC: HEART FAILURE VOL.6,NO.8,2018

▪ Obese HFpEF/HFpEF with pulmonary vascular disease

▪ HFpEF with arterial stiffening

▪ HFpEF with endothelial dysfunction.

1 Zakeri R, Cowie MR Heart2018;0:1–8

doi:10.1136/heartjnl-2016-310790

Chẩn đoán suy tim EF bảo tồn dựa trên cơ chế hay dựa trên khía cạnh lâm sàng ?

The main differences are that patients with HFpEF have lower rates of acute

pulmonary edema and paroxysmal nocturnal dyspnea

Triệu chứng và dấu hiệu HFpEF

Triệu chứng tương tự suy tim EF giảm

Bhatia RS, et al N Engl J Med 2006;355(3):260–269.

The main differences are that patients with HFpEF have lower rate of S3 heart sounds and

chest radiographic signs and a higher rate of bilateral ankle edema

Triệu chứng và dấu hiệu HFpEF

Triệu chứng tương tự suy tim EF giảm

HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; S3, third heart sound; S4, fourth heart sound.

Bhatia RS, et al N Engl J Med 2006;355(3):260–269.

Lưu đồ chẩn đoán suy tim

Siêu âm tim là bắt buộc

để chẩn đoán suy tim

1 Ponikowski P, et al Eur J Heart Fail 2016 doi: 10.1002/ejhf.592

Đồng thuận ESC HFpEF: Điểm chẩn đoán và

khả năng bị HFpEF

•The ESC is developing an Heart Failure Association Pre-test probability, Echocardiography,

Further advanced work-up, and Final etiology (HFA-PEFF) score

•This was presented at the Heart Failure Congress in 2018, but at the time of this recording, the

manuscript was not published

Pieske B ESC HFA Congress 2018 Abstract

Thang điểm mới chẩn đoán HFpEF:

https://www.mdcalc.com/h2fpef-score-heart-failure-preserved-ejection-fraction#next-steps

•The odds of HFpEF double for each 1 unit score increase

•The maximum number of points is 9 and that correlates to a probability of HFpEF that goes above 95%

Thang điểm mới chẩn đoán HFpEF:

Reddy YNV et al Circulation 2018;138:861-870

HFpEF có tiên lượng xấu ? Suy tim EF bảo tồn có tiên lượng giống Suy tim EF giảm ?

Overall mortality in HFpEF compared to

other cardiovascular trials

4.6 5.3 5.5 7.1 7.5

11 11.5

43

69 73

01020304050607080

HF hospitalization in HFpEF compared

to other cardiovascular trials

ACCORD [Action to Control Cardiovascular Risk in Diabetes], second Australian National Blood Pressure trial [ANBP-2], ACTION [A Coronary disease Trial Investigating Outcome with Nifedipine], Losartan Intervention for Endpoint reduction in hypertension [LIFE], VALUE [Valsartan Antihypertensive Long-term Use Evaluation], Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial [ALLHAT], and Hypertension in the Very Elderly Trial [HYVET]) and heart failure– preserved ejection fraction (HF-PEF) trials (DIG-PEF, CHARM-Preserved, and I-PRESERVE); CV, cardiovascular; HFpEF, Heart failure with preserved ejection fraction

Tử vong ở bệnh nhân HFpEF sv HFrEF

HFmrEF, Heart Failure with mid-range ejection fraction; HFpEF, Heart failure with preserved ejection fraction;

HFrEF, Heart failure with reduced ejection fraction

A recent international, prospective, multi-ethnic cohort

study has shown that mortality rate in HFpEF is lower than

HFrEF (p=0.0013) 1

The overall mortality rate was consistently lower in the placebo arms of HFpEF trials (I-Preserve and CHARM-Preserve) versus HFrEF trials (CHARM-Added and CHARM- Alternative) 2

HFrEF trials HFpEF trials

I-Preserve CHARM-Preserve CHARM-Added CHARM-Alternative

Tỉ lệ tử vong ở bệnh nhân HFpEF thấp hơn HFrEF

1 Lam CSP et al Eur Heart J 2018;39(20):1770-1780

2 Campbell RT et al J Am Coll Cardiol 2012;60:2349–56

High rate of HF hospitalizations in HFpEF and HFrEF, however a higher rate of non-HF

readmissions is observed among patients with HFpEF

According to 5-year outcomes analysis of patients

in the GWTG-HF registry, a lower rate of HF readmissions was observed in HFpEF than HFrEF2

*Study cohort included 40239 patients from 220 hospital sites in the GWTG-HF registry between January 1, 2005, and December 30,

2011 Patients in the GWTG-HF registry were hospitalized for acute decompensated heart failure.

HFrEF (EF<40%); HFbEF (40%≤EF< 50%); HFpEF (EF ≥50%) GWTG-HF, Get With The Guidelines-Heart Failure; HFpEF, heart failure with preserved ejection fraction.

Xu hướng nhập viện ở bệnh nhân

suy tim EF bảo tồn qua nc quan sát

1 Cheng RK et al Am Heart J 2014;168, 721–730; 2 Shah KS et al J Am Coll Cardiol 2017;70(20):2476-2486

Điều trị HFpEF chưa xác định ? Mục tiêu điều trị

4

Ponikowski P et al Eur Heart J 2016;37(27):2129–200

HFpEF=Heart failure with preserved ejection fraction; QoL=Quality of life

• Screen for comorbidities and treat to improve symptoms if present

• Diuretics for congestion to alleviate symptoms and signs

• Living with co-morbidities (e.g hypertension, diabetes)

• Highly symptomaticand have poor QoL

• Management of co-morbidities

• Alleviate symptoms and improve well-being

Hướng dẫn ACC/AHA/HFSA về HFpEF

F

Nhưng…

1 Ponikowski P et al Eur Heart J 2016;37(27):2129 –200

No treatment has yet been shown, convincingly, to reduce morbidity or mortality in patients with HFpEF or

HF=Heart failure; HFmrEF=Heart failure with mid-range ejection fraction; HFpEF=Heart failure with preservedejection fraction

I-PRESERVE TOPCAT

Tất cả nghiên cứu về HFpEF không

giảm kết cục lâm sàng

21

Cleland JGF,et al Eur Heart J 2006;27:2338-2345; Massie BM, et al N Engl J Med.2008;359:2456-67; Yusuf S, et al Lancet.2003;363:777-781

Kết quả nghiên cứu TOPCAT theo vùng

địa lý

Mild benefit of spironolactone in HFpEF

Chúng ta sẽ có một điều trị hiệu quả

cho HFpEF ?

PARAMOUNT: thử nghiệm pha 2 duy nhất về HFpEF có kết quả dương tính

Improvement in NYHA Class

Worsened Unchanged Improved

0 10 20 30 40 50 60 70 80 90 100 Percent of Patients

Change in Left Atrial Volume (ml)

LCZ696 Valsartan

Solomon et al Lancet 2012

HFpEF patients suffer from a high mortality rate compared to age-matched general population, mainly driven by high CV mortality, however it is lower than HFrEF with a greater proportion of non-CV deaths

High rate of HF hospitalizations in HFpEF and HFrEF, however a higher rate of non-HF

readmissions is observed among patients with HFpEF With the high burden and resource

utilization of recurrent hospitalizations, analysis taking into account the recurrent events helps in identifying better treatment targets

AF, atrial fibrillation; CAD, coronary artery disease; CV, cardiovascular; HF, heart failure; HFpEF, heart failure with preserved ejection fraction;

HFrEF, heart failure with reduced ejection fraction; LV, left ventricular.

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lắng nghe