1 phong ngua, dieu tri som suy tim HN LK 2020 (8h25 8h45)

40% instead of 35% New terminology Addition of natriuretic peptides in diagnostic criterion HF : heart failure LVEF : left ventricular ejection fraction LAE : left atrial enlargement LVH

Phòng ngừa và điều trị sớm suy tim

PGS TS Nguyễn Văn Trí Đại học Y dược TP HCM P.Chủ tịch Hội Lão khoa Việt Nam Chủ tịch Hội Lão khoa TP HCM

ĐÁI THÁO ĐƯỜNG

MỆT NGỰC HOẶC KHÓ THỞ …

SUY TIM ?

Cận lâm sàng gì?

ECG và siêu âm tim

Đủ loại trừ suy tim chưa ?

1

PHÂN LOẠI SUY TIM

2

2016 ESC Guidelines Heart Failure1

New Heart Failure terminology : HFrEF, HFmrEF, HFpEF

1 Symptoms +/- Signs Symptoms +/- Signs Symptoms +/- Signs

2 LVEF < 40% LVEF 40-49% LVEF ≥ 50%

3 - 1 Elevated levels of natriuretic peptides

(NT-proBNP > 125 ng/L)

2 At least one additional criterion

a Relevant structural heart disease (LVH and/or LAE)

b Diastolic dysfunction

1 Elevated levels of natriuretic peptides proBNP > 125 ng/L)

(NT-2 At least one additional criterion

a Relevant structural heart disease (LVH and/or LAE)

b Diastolic dysfunction

Changes ESC Guidelines

2012 ?

40% instead of 35% New terminology Addition of natriuretic peptides in diagnostic criterion

HF : heart failure LVEF : left ventricular ejection fraction LAE : left atrial enlargement LVH : left ventricular hypertrophy

1 Ponikowski P et al (2016) European Heart Journal doi:10.1093/eurheartj/ehw128

3

Đái tháo đường:

Nguy cơ độc lập dẫn đến suy tim

1 Available at: http://diabetes.niddk.nih.gov/dm/pubs/stroke/ Last accessed Dcember

2012

2. Van der Horst et al (2010) Neth Heart J 18(4):190-196

3 Çiftel S et al., Diabetes Res Clin Pract, 96:179–86, 2012

4. Neuhold et al (2011) Eur J Clin Invest 41(12):1292-1298

5. Bauters et al (2003) Cardiovasc Diabetol 2:1-16

CAD: Coronary artery disease; HF: Heart failure

HF

Potential mechanisms linking diabetes to HF 5

Diabetes

Endothelial dysfunction

Hemostatic disorders

CAD

angiopathy

Micro-Myocardial fibrosis

Abnormal metabolism

Diabetic cardiomyopathy

• Diabetic 2 and 5 relative risk of

developing HF compared with

non-diabetics2

• Approximately 45% diastolic heart failure

are in diabetic patients3

5

Các thuốc được chứng minh

trên Suy Tim PSTM giảm

6

TL: Ponikowski P 2016 ESC Guideline for the diagnosis

and treatment of acute and chronic heart failure Eur H J,

CI = confidence interval; DAPA = dapagliflozin; hHF = hospitalization for heart failure; HR = hazard ratio; N = number of patients.

In House Data, AstraZeneca Pharmaceuticals LP CSR D1693C00001.

27%

DAPA-HF: thay đổi NT-proBNP

Vai trò của NT-proBNP trong suy tim

6

CHUỖI BỆNH LÝ TIM MẠCH

NMCT

ĐỘT TỬ

RL nhịp tim & RL chức năng thất trái

Lớn thất trái

Suy tim NYHA

Tử vong do suy bơm

Phì đại thất trái

RL chức năng tâm trương

YTNC

Tăng HA Bệnh ĐMV Bệnh van tim Béo phì

ĐTĐ

Bệnh thận

7

2017 ACC/AHA HF Guideline

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

8

2017 ACC/AHA HF Guideline

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

9

COR LOE Recommendation Comment/ Rationale

IIa B-R

For patients at risk of developing HF , natriuretic peptide biomarker–based screening followed by team-based care, including a cardiovascular specialist optimizing GDMT, can be useful to

prevent the development of left ventricular dysfunction (systolic or diastolic) or new-onset HF.

NEW : New data suggest that natriuretic peptide biomarker

screening and early intervention may prevent HF

NT-proBNP guided prevention for Diabetes

PONTIAC trial: NT-proBNP guided prevention for Diabetes

• History of cardiac disease

• Signs of cardiac disease in the electrocardiogram

• ST-T-wave abnormalities or a bundle branch block

2) Start ACEI if RAS antagonist or beta-blocker is not started 3) Increase dose of medication till NT-proBNP decreased by 50% or below normal range or a tolerated dose achieved

Intensified group (n=150) Control group (n=150)

None due to cardiac disease 3 out 5 due to cardiac disease

PONTIAC trial: NT-proBNP guided prevention for Diabetes

Result

2017 ACC/AHA HF Guideline

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

14

2017 ACC/AHA HF Guideline

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

15

Biomarkers for Diagnosis

COR LOE Recommendation Comment/

Rationale

In patients presenting with dyspnea , measurement of natriuretic peptide biomarkers is useful to support a diagnosis

or exclusion of HF.

MODIFIED : 2013 acute and chronic

recommendations have been combined into a diagnosis section

2017 ACC/AHA HF Guideline

16

NT-proBNP predicts heart failure in diabetes

Objective: examined the individual and combined effect of NT-proBNP, high-sensitivity cardiac

troponin T (hs-cTnT), interleukin-6 (IL-6), and hs-CRP on the prediction of heart failure incidence or

progression in patients with type 2 diabetes

Study design: case-cohort study, 11,140 patients with type 2 diabetes at high risk of cardiovascular

events who participated in Action in Diabetes and Vascular Disease: Preterax and DiamicronModified

Release Controlled Evaluation (ADVANCE) study

Toshiaki Ohkuma et al Cardiac Stress and Inflammatory Markers as Predictors of Heart Failure in Patients With Type 2 Diabetes: The ADVANCE Trial.Diabetes Care Volume 40, September 2017 17

NT-proBNP predicts heart failure in diabetes

NT-proBNP showed the strongest association with heart failure

Toshiaki Ohkuma et al Cardiac Stress and Inflammatory Markers as Predictors of Heart Failure in Patients With Type 2 Diabetes: The ADVANCE Trial.Diabetes Care Volume 40, September 2017 18

2017 ACC/AHA HF Guideline

▪ Suy tim sớm khi có khó thở, khoảng 45% phân suất tống máu bảo tồn

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