Từ tăng huyết áp đến suy tim - Trần Văn Huy

uộc) 
Loại bệnh nhân Thuốc đầu tiên 
ưu tiên 
Thêm thuốc thứ 2 ưu tiên 
nếu cần để đạt HA < 140/90 
mmHg 
Thêm thuốc thứ 3 để đạt 
HA < 140/90 mmHg* 
THA và ĐTĐ CTTA /ƯCMC CKCa hay thiazide; Thuốc thứ 2 thay thế 
(thiazide hay CKCa) 
THA và bệnh 
thận mạn 
CTTA/ƯCMC CKCa hay lợi tiểu thiazide Thuốc thứ 2 thay thế 
(thiazide hay CKCa) 
THA và bệnh 
ĐMV lâm sàng 
BB+ 
CTTA/ƯCMC 
CKCa hay thiazide Thuốc thứ 2 thay thế 
(thiazide hay CKCa) 
THA và tiền sử 
đột quỵ 
ƯCMC /CTTA Lợi tiểu thiazide hay CKCa Thuốc thứ 2 thay thế (CKCa 
hay lợi tiểu thiazide) 
THA và suy tim CTTA/ƯCMC + BB + spironolactone khi suy tim độ II- IV + lợi tiểu 
thiazide, quai khi ứ dịch. CKCa nhóm Dihydropyridine có thể thêm vào 
nếu cần kiểm soát HA 
CKCa: chẹn kênh Canxi; UCMC: ức chế men chuyển; CTTA: chẹn thụ thể angiotensin II; BB: chẹn bêta 
* Không đạt mục tiêu phối hợp 4 thuốc: xem xét thêm chẹn beta, kháng aldosterone hay 
nhóm khác (giãn mạch, chẹn alpha, kháng alpha trung ương) 
 10 
Đích HA trong THA Suy Tim và Cập 
Nhật Điều Trị Theo KC Suy Tim 
ACC/AHA/HFSA 2017 & ESC 2016 
• Đích HA: 
– Dự phòng suy tim: 
– THA suy tim EF bảo tồn: 
– THA suy tim EF giảm: 
130/80 mmHg 
Yancy, et. al. ACC/AHA/HFSA 2017 Heart Failure Focused Update 
Hypertension 
COR LOE Recommendations 
Comment/ 
Rationale 
Treating Hypertension to Reduce the Incidence of HF 
I B-R 
In patients at increased risk, stage A HF, 
the optimal blood pressure in those 
with hypertension should be less than 
130/80 mm Hg. 
NEW: 
Recommendation 
reflects new RCT data. 
Yancy, et. al. ACC/AHA/HFSA 2017 Heart Failure Focused Update 
Hypertension 
COR LOE Recommendations 
Comment/ 
Rationale 
Treating Hypertension in Stage C HFrEF 
I C-EO 
Patients with HFrEF and hypertension 
should be prescribed GDMT titrated 
to attain systolic blood pressure less 
than 130 mm Hg. 
NEW: Recommendation 
has been adapted from 
recent clinical trial data 
but not specifically 
tested per se in a 
randomized trial of 
patients with HF. 
Yancy, et. al. ACC/AHA/HFSA 2017 Heart Failure Focused Update 
Hypertension 
COR LOE Recommendations 
Comment/ 
Rationale 
Treating Hypertension in Stage C HFpEF 
I C-LD 
Patients with HFpEF and persistent 
hypertension after management of 
volume overload should be 
prescribed GDMT titrated to attain 
systolic blood pressure less than 130 
mm Hg. 
NEW: New target goal 
blood pressure based on 
updated interpretation 
of recent clinical trial 
data. 
For many common antihypertensive agents, including alpha blockers, beta blockers, and 
calcium channel blockers, there are limited data to guide the choice of antihypertensive 
therapy in the setting of HFpEF. ACE inhibitor, ARB (especially mineralocorticoid receptor 
antagonists) and ARNI would represent the preferred choice. 
Yancy, et. al. ACC/AHA/HFSA 2017 Heart Failure Focused Update 
Pharmacological Treatment for Stage C HF 
With Preserved EF 
I B 
Systolic and diastolic blood pressure 
should be controlled in patients with 
HFpEF in accordance with published 
clinical practice guidelines to prevent 
morbidity 
2013 recommendation 
remains current. 
I C 
Diuretics should be used for relief of 
symptoms due to volume overload in 
patients with HFpEF. 
2013 recommendation 
remains current. 
COR LOE Recommendations 
Comment/ 
Rationale 
IIa C 
The use of beta-blocking agents, ACE 
inhibitors, and ARBs in patients with 
hypertension is reasonable to control blood 
pressure in patients with HFpEF. 
2013 
recommendation 
remains current. 
Yancy, et. al. ACC/AHA/HFSA 2017 Heart Failure Focused Update 
IIb B-R 
In appropriately selected patients with 
HFpEF (with EF ≥45%, elevated BNP levels 
or HF admission within 1 year, estimated 
glomerular filtration rate >30 
mL/min, creatinine <2.5 mg/dL, potassium 
<5.0 mEq/L), aldosterone receptor 
antagonists might be considered to 
decrease hospitalizations. 
NEW: Current 
recommendation 
reflects new RCT 
data. 
Pharmacological Treatment for Stage C HF 
With Preserved EF 
COR LOE Recommendations 
Comment/ 
Rationale 
IIb B 
The use of ARBs might be considered to 
decrease hospitalizations for patients with 
HFpEF. 
2013 
recommendation 
remains current. 
Yancy, et. al. ACC/AHA/HFSA 2017 Heart Failure Focused Update 
CHARM Program: Reduction in CHF 
hospitalization 
Val-HeFT: Valsartan Heart Failure Trial. HF = heart failure. 
Cohn JN et al. N Engl J Med. 2001;345:1667-1675. 
3 6 9 12 15 18 21 24 27 
0 
65 
70 
75 
80 
85 
90 
95 
100 
Months 
Event-Free 
Probability 
P < 0.001 
27.5% Risk Reduction 
0 
Valsartan 
Placebo 
Val-HeFT: HF-Related Hospitalizations* 
30 
Val-HeFT: Reduction in Mortality with 
Valsartan (No ACE-I Subgroup) 
50 
100 
0 3 6 9 12 15 18 21 24 27 30 
P = 0.017 
60 
70 
80 
90 
Time Since Randomization (months) 
33% Risk reduction 
Valsartan, n=185 
Placebo, n=181 
Proportion 
Survived 
Maggioni et al. J Am Coll Cardiol 2002;40:1414-21 
Điều trị THA với HFrEF theo ESC 2016 
Treatment of HFrEF Stage C and D 
Yancy, et. al. ACC/AHA/HFSA 2017 Heart Failure Focused Update 
Pharmacological Treatment for Stage C HF 
With Reduced EF 
Renin-Angiotensin System Inhibition With ACE-Inhibitor or ARB 
or ARNI 
COR LOE Recommendations 
Comment/ 
Rationale 
I 
ARNI: 
B-R 
In patients with chronic symptomatic 
HFrEF NYHA class II or III who tolerate 
an ACE inhibitor or ARB, replacement by 
an ARNI is recommended to further 
reduce morbidity and mortality. 
NEW: New clinical trial 
data necessitated this 
recommendation. 
Yancy, et. al. ACC/AHA/HFSA 2017 Heart Failure Focused Update 
 A Comparison of Angiotensin Receptor-
Neprilysin Inhibition (ARNI) With ACE Inhibition 
in the Long-Term Treatment of Chronic Heart 
Failure With a Reduced Ejection Fraction 
Milton Packer, John J.V. McMurray, Akshay S. Desai, Jianjian 
Gong, Martin P. Lefkowitz, Adel R. Rizkala, Jean L. Rouleau, 
Victor C. Shi, Scott D. Solomon, Karl Swedberg and Michael R. 
Zile for the PARADIGM-HF Investigators and Committees 
0 
16 
32 
40 
24 
8 
Enalapril 
(n=4212) 
360 720 1080 0 180 540 900 1260 
Days After Randomization 
4187 
4212 
3922 
3883 
3663 
3579 
3018 
2922 
2257 
2123 
1544 
1488 
896 
853 
249 
236 
LCZ696 
Enalapril 
Patients at Risk 
1117 
K
a
p
la
n
-M
e
ie
r 
E
s
ti
m
a
te
 o
f 
C
u
m
u
la
ti
v
e
 R
a
te
s
 (
%
) 
914 
LCZ696 
(n=4187) 
HR = 0.80 (0.73-0.87) 
P = 0.0000002 
Number needed to treat = 21 
PARADIGM-HF: Cardiovascular Death or Heart Failure 
Hospitalization (Primary Endpoint) 
Enalapril 
(n=4212) 
LCZ696 
(n=4187) 
HR = 0.80 (0.71-0.89) 
P = 0.00004 
Number need to treat = 32 
K
a
p
la
n
-M
e
ie
r 
E
s
ti
m
a
te
 o
f 
C
u
m
u
la
ti
v
e
 R
a
te
s
 (
%
) 
Days After Randomization 
4187 
4212 
4056 
4051 
3891 
3860 
3282 
3231 
2478 
2410 
1716 
1726 
1005 
994 
280 
279 
LCZ696 
Enalapril 
Patients at Risk 
360 720 1080 0 180 540 900 1260 
0 
16 
32 
24 
8 
693 
558 
PARADIGM-HF: Cardiovascular Death 
LCZ696 
(n=4187) 
Enalapril 
(n=4212) 
Hazard 
Ratio 
(95% CI) 
P 
Value 
Primary 
endpoint 
914 
(21.8%) 
1117 
(26.5%) 
0.80 
(0.73-0.87) 
0.0000002 
Cardiovascular 
death 
558 
(13.3%) 
693 
(16.5%) 
0.80 
(0.71-0.89) 
0.00004 
Hospitalization 
for heart failure 
537 
(12.8%) 
658 
(15.6%) 
0.79 
(0.71- 0.89) 
0.00004 
PARADIGM-HF: Effect of LCZ696 vs Enalapril on 
Primary Endpoint and Its Components 
Systolic blood pressure during run-in and after 
randomization 
• Compared with the 
randomization level, the mean 
SBP at 8 months was 
3.2 ± 0.4 mmHg lower in the 
sacubitril/valsartan group than 
in the enalapril group 
(p<0.001) 
• When modeled as a time-
dependent covariate, the 
difference in BP was not a 
determinant of the 
incremental benefits of 
sacubitril/valsartan 
BP, blood pressure; SBP, systolic blood pressure 
McMurray et al. N Engl J Med 2014;371:993–1004 and supplementary appendix 
140 
120 
100 
80 
60 
SB
P
 (
m
m
H
g)
–11w 4m 8m 1yr 2yrs 3yrs 
Time 
R
an
d
o
m
iz
at
io
n
Enalapril 
Sacubitril/valsartan 
Mean difference (sacubitril/valsartan–enalapril): 
–2.70 (–3.07, –2.34) (mmHg) 
p value: <0.001 
In heart failure with reduced ejection fraction, when 
compared with recommended doses of enalapril: 
LCZ696 was more effective than enalapril in . . . 
• Reducing the risk of CV death and HF hospitalization 
• Reducing the risk of CV death by incremental 20% 
• Reducing the risk of HF hospitalization by incremental 21% 
• Reducing all-cause mortality by incremental 16% 
• Incrementally improving symptoms and physical limitations 
LCZ696 was better tolerated than enalapril . . . 
• Less likely to cause cough, hyperkalemia or renal impairment 
• Less likely to be discontinued due to an adverse event 
• More hypotension, but no increase in discontinuations 
• Not more likely to cause serious angioedema 
PARADIGM-HF: Summary of Findings 
10% 
Angiotensin Neprilysin Inhibition With LCZ696 Doubles 
Effect on Cardiovascular Death of Current Inhibitors of the 
Renin-Angiotensin System 
20% 
30% 
40% 
ACE 
inhibitor 
Angiotensin 
receptor 
blocker 
0% 
%
 D
e
c
re
a
s
e
 i
n
 M
o
rt
a
li
ty
18% 
20% 
Effect of ARB vs placebo derived from CHARM-Alternative trial 
Effect of ACE inhibitor vs placebo derived from SOLVD-Treatment trial 
Effect of LCZ696 vs ACE inhibitor derived from PARADIGM-HF trial 
Angiotensin 
neprilysin 
inhibition 
15% 
Conclusion: Suggested Empirical Antihypertensive Strategy in HF 
Patients With Persisting Hypertension 
Messerli, F.H. et al. J Am Coll Cardiol HF. 2017;5(8):543–51. 
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