Tối ưu hoá điều trị suy tim mạn - Châu Ngọc Hoa

TỐI ƯU HOÁ ĐIỀU TRỊ SUY TIM MẠN 
 PGS. TS. CHÂU NGỌC HOA 
 ĐHYD TPHCM 
“Signed” by HFA / ESC/ HFSA/ ACC/ AHA 
Downloaded from  at Amgen, Inc-- on May 20, 2016 
www.escardio.org/guidelines 
3 
In the year 2016, by applying all evidence-based 
discoveries, heart failure is becoming a preventable 
and treatable disease. 
Objectives in the management of heart failure 
• Improve clinical status 
• Improve functional capacity and quality of life 
• Prevent hospital readmission 
• Reduce mortality 
3 key points 
to optimize treatment of a patient with chronic heart failure 
PATIENT’S 
JOURNEY 
RIGHT 
TIMING 
RIGHT 
ACTION 
Heart failure patients suffer 
from recurrent hospitalization 
1. Gheorghiade M et al. Am J Cardiol. 2005;96:11-17. 
With each hospitalization, there is 
likely myocardial and renal damage 
which contributes to progressive left 
ventricular or renal dysfunction, 
leading to an inevitable downward 
spiral.1 
Patients are stable by discharge 
“It is important to consider that once hospitalized heart failure patients are 
stabilized by discharge, the majority of them should be considered to be in 
a chronic heart failure state at a significantly high risk for adverse 
outcomes.”1 
1. Gheorghiade M et al. Recognizing hospitalized heart failure as an entity and developing new therapies to improve outcomes. Academics’, clinicians’, industry’s, regulators’, and payers’ perspectives. Heart Failure Clin. 2013.9;285-290. 
Post-discharge, the prognosis is poor 
“Hospitalized heart failure is associated with unacceptable high post-
discharge mortality and rehospitalization rate.”1 
1. Gheorghiade M et al. Recognizing hospitalized heart failure as an entity and developing new therapies to improve outcomes. Academics’, clinicians’, industry’s, regulators’, and payers’ perspectives. Heart Failure Clin. 2013.9;285-290. 
Mortality is particularly high 
in the early phase after hospitalization 
1. Marti NC et al.Timing and duration of interventions in clinical trials for patients with hospitalized heart failure. Circ Heart Fail. 2013;6:1095-1101. - Changes in risk profile after hospitalization. Hazard ratio of all-cause mortality after discharge from hospital for first hospitalization. 
All-cause mortality after discharge for HF is high during the 1st month1 
Time after discharge from hospital (months) 
Rehospitalization is particularly high 
in the early phase after hospitalization: 
1 out of 2 patients rehospitalized within 2 months 
1. O’Connor CM et al. Causes of death and rehospitalization in patients hospitalized with worsening heart failure and reduce lef t ventricular ejection fraction: results from efficacy of vasopressin antagonism in heart failure outcome stuy with tolvaptan (EVEREST) program. Am Heart J. 2010;159:841-849.e1. 
EVEREST 
Timing of major causes 
of first hospitalization1 
[2159 patients] 
The high risk in the weeks to months post-discharge 
may be viewed as the “vulnerable phase” 
1. Krumholz HM. Post-hospital Syndrome – An acquired, Transient Condition of Generalized Risk . NEJM. 2013;368;2 
2. Marti NC et al. Timing and duration of interventions in clinical trials for patients with hospitalized heart failure. Circ Heart Fail. 2013;6:1095-1101. 
The post-discharge period is described as an “acquired, transient condition of generalized risk” or “a period of vulnerability.”1 
Comprehensive strategies should focus on factors during hospitalization and also during the early recovery period soon after 
discharge to target stressors that probably contribute to the vulnerability of patients.1,2 
Post-discharge follow-up & survival 
1. Metra M et al. Postdischarge assessment after a heart failure hospitalization: the next step forward. Circulation. 2010;122:1782-1785. 
. 
A review of post-discharge 
assessment (30 days) 
in more than 10 500 
patients from the National 
Ambulatory Care Reporting 
System (Canada)1 
Death 
(% of patients) 
Hospitalization is the key moment 
to optimize treatment 
to prevent post-discharge mortality and rehospitalization 
1. Psotka MA, Teerlink JR. Strategies to Prevent Postdischarge Adverse Events Among Hospitalized Patients with Heart Failure. Heart Failure Clin. 2013;9:303-320. 
Prevention of adverse outcomes in hospitalized HF patients relies on preventing HF progression by:1 
initiating and titrating evidence-based therapy 
ensuring continued adherence to that therapy 
preventing and treating patient comorbidities 
Hospitalization is the key moment 
to optimize treatment 
2013 ACCF/ AHA guidelines for HF 
1. Yancy C et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240-e327. 
Recommendations for hospital discharge1 
www.escardio.org/guidelines 
 6 
 Therapeutic 
 algorithm for 
 a patient with 
symptomatic HFrEF 
Elevated heart rate at hospital discharge 
predicts one-year mortality (OFICA) 
1. Logeart D et al. Raised heart rate at discharge after acute heart failure is an independent predictor of one-year mortality. Eur Heart J. 2012;33(Abst Suppl):485. [ABSTRACT] 
Su
rv
iv
al
 (
%
) 41% increase in 
 one-year mortality1 
 P = 0.01 
N=1658 (170 hospitals); Mean HR at discharge:71 bpm; 1 year mortality: 33% 
Time (days) 
• 
• 
• 
• 
• 
 HR Reduction as a Therapeutic Target 
Reduce myocardial oxygen consumption 
Improve contractile performance 
Improve diastolic filling 
Reduce risk of VF and sudden death 
Promote reverse remodeling 
BUTBeta-blockers remain underutilized and 
 underdosed in clinical practice (and in trials) 
 Kitai et al., Curr Treat Options Cardio 2016;18:13 
Underutilization of Beta-Blockers 
Gheorghiade et al, Cong Heart Fail 2012;18:9 
Practical guidance on the use of beta-blockers in 
patients with heart failure 
23 
Optimization of treatment before discharge 
Pharmacological treatment in CHF 
recommended in the 2016 ESC guidelines 
1. McMurray J et al. European Society of Cardiology Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012. Eur Heart J. 2012;33:1787-1847. 
. 
1 
B
N
P
, 
p
g
/m
l 
L
V
E
F
, 
%
 ETHIC-AHF: effects of the early co-administration 
of ivabradine and beta-blockers in patients with heart failure 
38 
36 
34 
46 
44 
42 
40 
200 
 0 
600 
400 
P=0.039 
P=0.02 
Hidalgo FJ, et al. Int J Cardiol (2016). 
• SOLVD (1991): 66% 
• US Carvedilol (1996): 90% 
• RALES (1999): 73% 
• CHARM-Alternative (2003): 45% 
• RAFT (2010): 35% 
• EMPHASIS (2011): 27% 
over the subsequent decadesin part due to 
lack of effect on death and downgrade in 
guideline recommendations 
However, Use Declined 
2016 ESC GUIDELINES 
Recommendations for 
initial management of 
a rapid ventricular rate 
in patients with heart 
failure and atrial 
fibrillation in the acute 
or chronic setting 
Guidelines that aren’t 
implemented don’t work 
3 key points 
to optimize treatment of a patient with chronic heart failure 
PATIENT’S 
JOURNEY 
RIGHT 
TIMING 
RIGHT 
ACTION