Suy Tim Mạn Ổn Định Tại Việt Nam Và Làm Thế Nào ĐểCải Thiện Điều Trị Có Hiệu Qủa Tối Ưu?

Despite disease-modifying medical therapy, patients with HF are at high risk of poor clinical outcomes 8 ~7% of patients receiving DMT died due to sudden cardiac death during median fo

Suy Tim Mạn Ổn Định Tại Việt Nam Và Làm Thế Nào Để

Cải Thiện Điều Trị Có Hiệu Qủa Tối Ưu?

Stable Heart Failure in Viet Nam Real and How to Improve Beyond for the Optimizing Therapy in HF

PGS TS BS TRẦN VĂN HUY FACC FESC

Phó Chủ Tịch Phân Hội Tăng Huyết Áp Việt Nam PCT Hội TMMT Chủ Tịch Hội Tim Mạch Khánh Hòa

HF is a progressive disease whereby cardiac structure

and function continue to deteriorate

5

 Increasing frequency of acute events with disease progression leads to high rates

of hospitalization and increased risk of mortality 1–7

Adapted from Gheorghiade et al 20052

HF, heart failure 1 Ahmed et al Am Heart J 2006;151:444–50; 2 Gheorghiade et

al Am J Cardiol 2005;96:11G–17G; 3 Gheorghiade, Pang J Am Coll Cardiol 2009;53:557–73; 4 Holland et al J Card Fail 2010;16:150–6; 5 Muntwyler et al Eur Heart J 2002;23:1861–6; 6

McCullough et al J Am Coll Cardiol 2002;39:60–9; 7 McMurray JJ

et al Eur Heart J 2012;33(14):1787–1847

Despite disease-modifying medical therapy, patients with

HF are at high risk of poor clinical outcomes

8

~7% of patients

receiving DMT died due

to sudden cardiac death during median follow-up of 27 months 3

Nearly 7% and 50% of

patients with HF die within 1 year and 5 years of diagnosis, respectively 1,2

Approximately 25% and 44 % of patients are readmitted

to hospital within 30 days and 1 year after discharge,

respectively 4,5

1 Mozaffarian D et al Circulation 2015;131:e29–322; 2 Maggioni

et al Eur J Heart Fail 2013;15:808–17; 3 Desai AS et al Eur

Heart J 2015;36:1990–97; 4 Greene et al Nat RevCardiol 2015;12:220–29; 5 Maggioni et al Eur J Heart Fail

2013;15:808–17

HF, heart failure; HFrEF, heart failure with reduced

ejection fraction; DMT, disease-modifying medical therapy

Thực Tế Suy Tim Mạn Tại VN

• Tỷ lệ chung? Chưa có con số thống kê chính xác

– Ước tính khoảng 320.000 đến 1.6 triệu người suy tim cần điều trị; 1-1.5%

• Điều trị nội khoa, can thiệp CRT ICD, Ghép Tim

• Tỷ lệ tử vong : Qua nghiên cứu cohort 233 BN suy tim mạn ổn định (55% HFrEF) nghiên cứu từ năm

2011 đến 2015, theo dõi trung bình 24,8 ± 13,5 tháng tại BV Nhân Dân Gia Định Tp HCM.

– Suy Tim độ I & II: 72,9%.

– Tử vong: 32% Nghi đột tử: 11,8%.

– Nhập viện 12 tháng: 42%

* Lê Thi Thu Hương Luận án NCS BV 7 /2018 DHYD TpHCM

Tỷ lệ thuốc điều trị bệnh nhân suy tim mạn

B: THA: 76%; ĐTĐ:21.1%; BMV:84,9%; RN:29,1%;COPD:37%; Van tim:10%

A Thu Thuy 500 ca suy tim điều trị BV CR; B Lê Thi Thu Hương Luận án NCS BV 7 /2018 DHYD TpHCM

A

B

38.2

64.3 26.6

61.8 54.9 57.1

87.1

Statin Nitrat Chẹn beta Digoxin Lợi tiểu khác Kháng aldostreone UCMC/CTTII

%

Làm thế nào cải thiện hiệu qủa tối

ưu ngay cả suy tim nhẹ NYHA II

Mục tiêu điều trị suy tim mạn

A post-hoc analysis from MERIT-HF (n=3991)1

Mean follow up, 1 year

An analysis from PARADIGM-HF (n=8399)2

Median follow up, 2.3 years

Patients with NYHA class II are at high risk of

sudden cardiac death

 MERIT HF post hoc analysis: the incidence of SCD is higher in patients with less

severe HF (NYHA class II), although total mortality rates increase with higher

NYHA class 1

 PARADIGM-HF analysis: 44.8% of NYHA class II HF CV deaths were SCDs 2

CV, cardiovascular; HF, heart failure; MERIT-HF, Metoprolol

11 CR/XL Randomised Intervention Trial in-Congestive Heart Failure;

NYHA, New York Heart Association; PARADIGM-HF, Prospective

comparison of ARNI with ACEI to Determine Impact on Global

Mortality and morbidity in Heart Failure;SCD, sudden cardiac

1.MERIT-HF Study Group Lancet 1999;353(9169):2001–7;

2 Desai AS et al Eur Heart J 2015;36:1990–7

NYHA Class II:

Mode of CV death

N=791 70

*Other CV death includes all CV deaths not ascribed to

pump failure or sudden death

Patients with stable NYHA Class II symptoms have

underlying disease progression

 Annual mortality 6-20%

 Over a million hospitalizations each year in US and Europe

 Post-discharge 25-30% mortality risk within 1 year

 Sudden death can occur without worsening of symptoms; 40%

die of SCD

 Stability of symptoms does not

mean lack of risk

 Patients have at-risk viable

vulnerable myocardium

 High risk of SCD with no warning

or worsening of symptoms

Reality of ‘stable NYHA class II’ 2

HF, heart failure; NYHA, New York Heart Association;

SCD, sudden cardiac death

1 Sabbah HN Eur J Heart Fail 2017;19:469–78; 2 Butler J et al

Eur J Heart Fail 2016;18,:350–52

 HF patients, even those in whom symptoms do not visibly progress, suffer silent

disease progression that often remains undetected; only manifesting with the

emergence of serious adverse outcomes, such as sudden death 1

Anthony S.L et al N Engl J Med 2010;363:2385-95.

Đánh Giá Ban Đầu Suy Tim

• Các xem xét chính:

– Xác định nguyên nhân và các yếu tố thúc đẩy suy tim nhập viện và tái nhập viện

– Lập kế hoạch chiến lược điều trị:

• Suy tim giảm EF (HFrEF): điều trị theo chứng cứ

• Suy tim EF bảo tồn (HFpEF): điều trị theo nguyên nhân triệu chứng, huyết động…

Effect of sacubitril/valsartan in patients with HFrEF: evidence from

PARADIGM-HF trial

Characteristic** Sacubitril/valsartan (n=4187) Enalapril (n=4212)

ACEi, angiotensin converting enzyme inhibitor; ARB, angiotensin

14 receptor blocker; BB, beta blocker; BNP, B-type natriuretic peptide;

CRT, cardiac resynchronization therapy; ICD, implantable cardioverter

defibrillator; IQR, interquartile range; LV, left ventricular; MRA,

mineralocorticoid receptor antagonist; NT-proBNP, N-terminal

pro-B-type natriuretic peptide; NYHA, New York Heart Association; SBP,

McMurray et al N Engl J Med 2014;371:993–1004

*All patients were receiving ACEi/ARB prior to enrollment in trial; **Mean ± standard deviation, unlessstated

 Patients in PARADIGM-HF could be perceived to be clinically stable: most of

them were in NYHA class II and on stable HF medication (ACEi/ARB*, BB, MRA where appropriate)

PARADIGM-HF trial: High risk of mortality and morbidity in a mostly NYHA II population previously on stable medication

McMurray et al N Engl J Med 2014;371:993–1004

CI, confidence interval; CV, cardiovascular; HF, heart failure;

HFrEF, heart failure with reduced ejection fraction

 Despite optimal treatment, death from CV causes or first HF hospitalization

(primary composite endpoint) occurred in 26.5% patients in the enalapril group

Outcome, n %

Sacubitril/

valsartan (n=4187)

Enalapril (n=4212)

Hazard ratio*

(95% CI) p value‡

Primary composite outcome

Death from CV causes or first

hospitalization for worsening of HF 914 (21.8) 1117 (26.5) 0.80 (0.73–0.87) <0.001

Death from CV causes 558 (13.3) 693 (16.5) 0.80 (0.71–0.89) <0.001

First hospitalization for worsening

of HF 537 (12.8) 658 (15.6) 0.79 (0.71–0.89) <0.001

*Calculated with the use of stratified cox proportional-hazard models; ‡Two-sided p-values calculated by means of a stratified

log-rank test without adjustment for multiple comparisons.

PARADIGM-HF: All-cause death and all-cause death or hospitalization

for any reason was reduced with sacubitril/valsartan

CI, confidence interval; HR, hazard ratio

McMurray et al N Engl J Med 2014;371:993–1004; Packer et al Circulation 2015;131:54–61

enalapril

12.6% with sacubitril/valsartan vs

enalapril

HR 0.84 (95% CI: 0.76–0.93)

p=0.0009

All-cause death or hospitalization

HR = 0.77 (0.67–0.89) P=0.001 HR= 0.60 (0.38-0.94)

P = 0.027

Sacubitril/valsartan was superior to enalapril in slowing the clinical progression in patients with HFrEF (1/3)

CI, confidence interval; HF, heart failure; HFrEF, heart failure

with reduced ejection fraction; HR, hazard ratio

Packer et al Circulation 2015;131:54–61

Click here for more details on clinical progression analysis

 Fewer HFrEF patients receiving sacubitril/valsartan were required to visit

emergency department for worsening of HF

Sacubitril/valsartan significantly reduced the number of SCDs compared with enalapril

Desai et al Eur Heart J 2015;36:1990-7

CI, confidence interval; SCD, sudden cardiac death; Sac/val,

sacubitril/valsartan

Hazard ratio=0.80 (95% CI: 0.68–0.94) p=0.008

Enalapril Sacubitril/valsartan

540 720 Days since randomization

Đánh Giá Cải Thiện Chất Lượng Cuộc Sống

ở Bệnh Nhân Suy Tim

Cải Thiện Chất Lượng Cuộc Sống

Treatment of HFrEF Stage C and D

Yancy, et al ACC/AHA/HFSA 2017 Heart Failure Focused Update

Pharmacological Treatment for Stage C HF

In patients with chronic symptomatic

HFrEF NYHA class II or III who tolerate

an ACE inhibitor or ARB, replacement by

NEW : New clinical trial data necessitated this recommendation.

Yancy, et al ACC/AHA/HFSA 2017 Heart Failure Focused Update

vong nhưng cải thiện chất lượng cuộc sống còn khiêm tốn.

• Nên cần sớm thay thế ƯCMC bằng Sacubitril/valsartan khi không chống chỉ định để không chỉ giảm thêm tử vong , đột

tử, tái nhập viện và đặc biệt còn cải thiện chất lượng cuộc sống ở bệnh nhân suy tim cao hơn so với các can thiệp khác ngay từ suy tim NYHA II