Nâng cao hiệu quả điều trị và giảm tái nhập viện ở người bệnh suy tim mạn: Vai trò của đơn vị suy tim - Nguyễn Thị Thu Hoài

Nâng cao hiệu quả điều trị và giảm tái 
nhập viện ở người bệnh suy tim mạn: 
Vai trò của đơn vị suy tim 
Improve treatment effectiveness and reduce 
readmisseion of chronic heart failure: 
Roles of Heart Failure Clinic 
TS. NGUYỄN THỊ THU HOÀI 
VIỆN TIM MẠCH QUỐC GIA VIỆT NAM 
Hội nghị Tim mạch Toàn quốc - Hà nội - 10/2016 
 Vietnam National Heart Association Congress of Cardiology 
Epidemiology of Heart Failure in US 
 Heart Disease and Stroke Statistics - 2016 Update 
Heart failure mentioned 
on 1 of 9 death certificates 
Circulation. 2015;132 
Heart Disease and Stroke Statistics--2016 Update 
Epidemiology of Heart Failure in US 
Treatment costs 
exceed $30 billion 
Circulation. 2015;132 
196219141900
1766
1416
0
500
1000
1500
2000
2500
3000
3500
1 2 3 4 5
Heart Failure Hypertension Ischemic heart disease
Rheumatic heart disease Congenital heart desease Pericardial disease
Arrhythmia Cardiomyopathies Endocarditis
Cerebrovascular disease PAD DVT
Trends of absolute numbers of heart failure and CVD 
patients at Vietnam National Heart Institute 
2003 2004 2005 2006 2007 
Systolic versus Diastolic Heart Failure 
Systolic Heart Failure 
• Clinical signs and 
symptoms – dyspnea, 
edema, fatigue 
• CXR – pulmonary 
congestion 
• Typical clinical response 
to treatment 
• Reduced systolic function: 
EF < 0.50 
Diastolic Heart Failure 
• Clinical signs and symptoms 
- dyspnea, edema, fatigue 
• CXR – pulmonary 
congestion 
• Typical clinical response to 
treatment 
• LV EF > 0.50 
• Diastolic dysfunction by cath 
LVEDP 
Proposed Definitions 
Circulation 2000;101:2118-2121 
HFREF versus HFPEF 
 1940s 1960s 1970s 1990s–2000 Future 
Evolving Models of Heart Failure 
Cardiorenal 
Digitalis and 
diuretic to 
perfuse kidneys 
Hemodynamic 
Vasodilators or 
positive inotropes 
to relieve ventricular 
wall stress 
Neurohormonal 
ACE inhibitors, 
beta blockers, and 
other agents to block 
neurohormonal 
activation 
 0s 0s s s–2 00 Future 
Pepper, Arch Intern Med 1999. 
Evolving Models of Heart Failure 
Genetic 
Therapies to 
modulate 
apoptosis, 
fibrosis, 
remodeling, 
arrhythmic 
substrates 
©2014 MFMER | 3307694-8 
Circula( on
©2014 MFMER | 3307694-9 
+
P<0.0001 
0 
A 
B 
C1 
C2 
D 
Ammar et al: Circulation 115:1563, 2007 
©2014 MFMER | 3307694-13 Circula( on
Hunt SA et al. Circulation 2009;119: e391-e479 
PREVENT ADVANCING HF 
©2014 MFMER | 3307694-43 
• 
• 
• 
Circ Curr+Heart+Fail+Reports+
Drug Therapy 
Clopidogrel 
Digoxin 
LMW 
Heparin 
CP943451-2 
ICD: Gold Standard of Sudden Cardiac Death Prevention 
N Engl J Med 1997;337:1576; N Engl J Med 2002;346:877 
0.0
0.2
0.4
0.6
0.8
1.0
0 1 2 3
P
ro
p
o
rt
io
n
 s
u
rv
iv
in
g
Follow-up (years) 
0.0
0.1
0.2
0.3
0.4
0 12 24 36 48 60
M
o
rt
a
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y
 r
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te
Follow-up (months) 
Secondary Prevention: AVID Primary Prevention: SCDHeFT 
Antiarrhythmic-drug group 
Defibrillator group 
Amiodarone 
ICD therapy 
Placebo 
 HR (95% CI) P 
Amiodarone vs placebo 1.06 (0.86-1.30) 0.53 
ICD therapy vs placebo 0.77 (0.62-0.96) 0.007 
Sinus node 
AV 
node 
Intraventricular Activation 
• Organized ventricular activation 
sequence 
• Coordinated septal and freewall 
contraction 
• Improved pumping efficiency 
Ventricular Resynchronization 
Stimulation therapy 
Conduction 
block 
Kass D. New dimensions in device-based therapy for heart failure–mechanisms of stimulation for heart failure. Heart Failure Society of America 1999. 
Therapies for End-Stage Heart 
Failure 
• Ventricular assist device 
• Bridge to transplant 
• Destination therapy 
• Heart transplant 
Hospital Visits for Congestive Heart Failure 
Initial Episode 
 21% 
Repeat Visit 79% 
Rates of readmission 
• 2% within 2 days 
• 25% within 1 month 
• 50% within 6 months 
Causes of Hospital Readmission for 
Congestive Heart Failure 
17% 
Other 
19% 
Failure to Seek 
Care 
16% 
Inappropriate Rx 
Rx Noncompliance 
 24% 
Diet Noncompliance 
24% 
Vinson J Am Geriatr Soc 1990;38:1290-5 
1. Prevent progression to next stage. 
2. Reduce admission 
3. Prevent re-admission 
4. Reduce mortality 
IMPROVE TREATMENT 
EFFECTIVENESS OF HEART FAILURE 
Cooperative Heart Failure Care - 
Heart Failure Clinic 
• How we lower re-hospitalization rate 
• How we increase the rate of using guideline-based 
medications. 
• How we educate HF patients, encourage their self-care, 
activate their motivation. 
• How we start HF rehab and make it a safe environment. 
• How we use IT 
• How we orchestrate the team 
Heart Failure Clinic 
• Physician 
• Nurse 
• Pharmacist 
• Case Manager 
• Nursing Director 
• Physical Therapist and/or Occupational Therapist 
• Care Transitions team member 
• Social Worker 
• Dietitian 
• Discharge Nurse 
• Respiratory Therapis 
Delivers individualized care 
1. To educate patient with knowledge of heart failure 
2. To improve self-care at home 
3. To decrease re-admission rate 
Case management 
1. Poor diet control, followed by fluid overload 
2. Did not keep targeted weight 
3. Poor medication compliance 
4. Did not note the change of their symptoms and signs. 
5. Miss clinical follow-up 
There are many reasons 
Re-admision, why? 
-> Self-care is very important! 
1. Low salt diet 
2. Fluid restriction 
After discharge, patients “know” 
BUT 
- Do we accurately intergrate this “know how” in to their 
REAL LIFE PRACTICE? 
- After discharge, patients do not understand how to 
adequately take care of themselves. 
Education program “one to one” interaction 
SET UP 
Goal 
Rise awareness of heart failure 
1. Demonstrate a future for them 
2. Help patients understand their disease severity 
3. Turn the hospitalization time into a self-care training 
course. 
Strategy to activate motivation 
1. Measure BP, HR, record I/O 
2. Measure body weight and maintain safe body weight 
3. Low salt diet, limit water intake 
4. Know when to report a worsening of disease 
5. Differentiate between HF medication types, know 
when to use diuretics. 
6. Maintain prescribed exercise and routin clinic visits. 
Educating self-care to HF patients 
1. As long as there is a team, does the team work? 
2. How to make it work? 
Team work 
1. For example: HF patient with EF 30% 
2. Nutritionist visiting: How to make it successful? 
3. Other team member function: How to make it 
successful? 
Art of orchestrating 
Exercise is great medicine but can 
sometimes be a hard pill to swallow. 
Exercise Program Suggestions for 
CHF Patients 
• Graded exercise test 
– Determine exercise capacity 
– Evaluate heart rate, blood pressure responses 
– Assess symptoms 
Exercise Program Suggestions for 
CHF Patients 
• Supervised cardiac rehabilitation program 
versus unsupervised setting (CHF not a 
covered diagnosis for CR in US, but many 
private insurances do cover it) 
• Intensity: moderate; 60% to 80% of VO2peak; 
HRR; RPE 12-14 
• Interval training to optimize results 
Exercise Prescription in CHF 
• Daily patient assessment (decompensation) 
– Rapid weight gain 
– Decreased BP 
– Increased symptoms 
– Increased arrhythmia 
Conclusions 
• Heart failure is a largely preventable disease: CAD, BP 
• Secondary prevention of heart failure mortality and 
morbidity is effective 
• Lifestyle modifications 
• Guideline Directed Medical Therapy (GDMT) 
• Defibrillators in selected cases 
• Cardiac resynchronization therapy 
• End stage treatments: VAD and transplant 
• Partnership: primary care and cardiology 
• Cooperative heart failure care unit plays important roles 
THANK YOU VERY MUCH!