Mục tiêu điều trị suy tim trước khi xuất viện

TỐI ƯU HOÁ ĐIỀU TRỊ SUY TIM MẠN
PGS. TS. CHÂU NGỌC HOA
ĐHYD TPHCM


“Signed” by HFA / ESC/ HFSA/ ACC/ AHA



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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


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

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

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

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

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

All-cause mortality after discharge for HF is high during the 1st month1

Time after discharge from hospital (months)

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.

Rehospitalization is particularly high
in the early phase after hospitalization:
1 out of 2 patients rehospitalized within 2 months

EVEREST
Timing of major causes
of first hospitalization1
[2159 patients]

1.

O’Connor CM et al. Causes of death and rehospitalization in patients hospitalized with worsening heart failure and reduce left 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.


The high risk in the weeks to months post-discharge
may be viewed as the “vulnerable phase”

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 1,2
during the early recovery period soon after
discharge to target stressors that probably contribute to the vulnerability of patients.

1.
2.

Krumholz HM. Post-hospital Syndrome – An acquired, Transient Condition of Generalized Risk . NEJM. 2013;368;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.


Post-discharge follow-up & survival

Death
(% of patients)

A review of post-discharge
assessment (30 days)
in more than 10 500
patients from the National
Ambulatory Care Reporting
System (Canada)1

1.
.

Metra M et al. Postdischarge assessment after a heart failure hospitalization: the next step forward. Circulation. 2010;122:1782-1785.


Hospitalization is the key moment
to optimize treatment

to prevent post-discharge mortality and rehospitalization

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

1.

Psotka MA, Teerlink JR. Strategies to Prevent Postdischarge Adverse Events Among Hospitalized Patients with Heart Failure. Heart Failure Clin. 2013;9:303-320.

Hospitalization is the key moment
to optimize treatment
2013 ACCF/ AHA guidelines for HF

Recommendations for hospital discharge1

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.


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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; 1 year mortality: 33%

Time (days)
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]


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

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
0

Hidalgo FJ, et al. Int J Cardiol (2016).