TỐI ƯU HOÁ ĐIỀU TRỊ SUY TIM MẠN PGS TS CHÂU NGỌC HOA ĐHYD TPHCM “Signed” by HFA / ESC/ HFSA/ ACC/ AHA Downloaded from http://circ.ahajournals.org/ at Amgen, Inc on May 20, 2016 In the year 2016,… by applying all evidence-based discoveries, heart failure is becoming a preventable and treatable disease www.escardio.org/guidelines Objectives in the management of heart failure • Improve clinical status • Improve functional capacity and quality of life • Prevent hospital readmission • Reduce mortality 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 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 Gheorghiade M et al Am J Cardiol 2005;96:11-17 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 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 postdischarge mortality and rehospitalization rate.”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 Hospitalization is the key moment to optimize treatment 2013 ACCF/ AHA guidelines for HF Recommendations for hospital discharge1 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 Therapeutic algorithm for a patient with symptomatic HFrEF www.escardio.org/guidelines Elevated heart rate at hospital discharge predicts one-year mortality (OFICA) Survival (%) 41% increase in one-year mortality1 P = 0.01 N=1658 (170 hospitals); Mean HR at discharge:71 bpm; year mortality: 33% Time (days) 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] 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 BUT…Beta-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 46 44 42 40 38 36 34 600 400 P=0.039 BNP, pg/ml LVEF, % ETHIC-AHF: effects of the early co-administration of ivabradine and beta-blockers in patients with heart failure P=0.02 200 Hidalgo FJ, et al Int J Cardiol (2016) However, Use Declined • SOLVD (1991): • US Carvedilol (1996): • RALES (1999): 66% 90% 73% • CHARM-Alternative (2003): 45% • RAFT (2010): 35% • EMPHASIS (2011): 27% over the subsequent decades…in part due to lack of effect on death and downgrade in guideline recommendations 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 key points to optimize treatment of a patient with chronic heart failure PATIENT’S JOURNEY RIGHT TIMING RIGHT ACTION ... hospital readmission • Reduce mortality key points to optimize treatment of a patient with chronic heart failure PATIENT’S JOURNEY RIGHT TIMING RIGHT ACTION Heart failure patients suffer from... All-cause mortality after discharge for HF is high during the 1st month1 Time after discharge from hospital (months) Marti NC et al.Timing and duration of interventions in clinical trials for patients... Guidelines that aren’t implemented don’t work key points to optimize treatment of a patient with chronic heart failure PATIENT’S JOURNEY RIGHT TIMING RIGHT ACTION