Nâng cao hiệu quả điều trị và giảm tái nhập viện ở người bệnh suy tim mạn vai trò của đơn vị suy tim

Hội nghị Tim mạch Toàn quốc - Hà nội - 10/2016
Vietnam National Heart Association Congress of Cardiology

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


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


Epidemiology of Heart Failure in US
Heart Disease and Stroke Statistics--2016 Update

Treatment costs
exceed $30 billion

Circulation. 2015;132


3500

Trends of absolute numbers of heart failure and CVD
patients at Vietnam National Heart Institute

3000

2500

1900

2000

1500

1914

1962

1766
1416

1000

500

0
1
2003

2

3
2005

2004

4

2006

5

2007

Heart Failure

Hypertension

Ischemic heart disease

Rheumatic heart disease

Congenital heart desease

Pericardial disease

Arrhythmia

Cardiomyopathies

Endocarditis

Cerebrovascular disease

PAD

DVT


Systolic versus Diastolic Heart Failure
HFREF versus HFPEF
Proposed Definitions

•

•
•
•

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
Circulation 2000;101:2118-2121


Evolving
Models
of
Heart
Failure
Evolving Models of Heart Failure
Genetic
Therapies to
Neurohormonal modulate
Hemodynamic
ACE inhibitors,

apoptosis,
Vasodilators or
beta blockers, and
Cardiorenal
fibrosis,
positive inotropes other agents to block remodeling,
Digitalis and
to relieve ventricular
neurohormonal
diuretic to
arrhythmic
wall stress
activation
perfuse kidneys
substrates

1940s
1940s
Pepper, Arch Intern Med 1999.

1960s
1960s

1970s
1970s

1990s–2000
1990s–2000

Future

Future


Circula( on


+
0

A
B
C1

C2
P<0.0001

D

Ammar et al: Circulation 115:1563, 2007


PREVENT ADVANCING HF

Circula( on
Hunt SA et al. Circulation 2009;119: e391-e479

©2014 MFMER | 3307694-13


•

•
•
Circ

Curr+Heart+Fail+Reports+


Drug Therapy
LMW
Heparin

Clopidogrel

Digoxin
CP943451-2


ICD: Gold Standard of Sudden Cardiac Death Prevention
Secondary Prevention: AVID

Primary Prevention: SCDHeFT

1.0

0.4

HR (95% CI)
1.06 (0.86-1.30)
0.77 (0.62-0.96)

Amiodarone vs placebo
ICD therapy vs placebo

P
0.53
0.007

Defibrillator group

0.3

0.6

Mortality rate

Proportion surviving

0.8
Antiarrhythmic-drug group

0.4

Amiodarone

0.2
ICD therapy

0.1

0.2

Placebo

0.0

0.0
0

1

2

Follow-up (years)

3

0

12

24

36

Follow-up (months)

N Engl J Med 1997;337:1576; N Engl J Med 2002;346:877

48

60


Ventricular Resynchronization
Sinus node

Intraventricular Activation

• Organized ventricular activation
sequence
AV
node

• Coordinated septal and freewall
contraction

• Improved pumping efficiency
Conduction
block
Stimulation therapy

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
Diet Noncompliance
24%

Rx Noncompliance
24%

16%
Inappropriate Rx

19%
Failure to Seek
Care
Vinson J Am Geriatr Soc 1990;38:1290-5

17%
Other


IMPROVE TREATMENT
EFFECTIVENESS OF HEART FAILURE
1. Prevent progression to next stage.
2. Reduce admission

3. Prevent re-admission
4. Reduce mortality


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
Delivers individualized care
•
•

•
•
•
•
•
•
•
•
•

Physician
Nurse
Pharmacist
Case Manager
Nursing Director
Physical Therapist and/or Occupational Therapist
Care Transitions team member
Social Worker
Dietitian
Discharge Nurse
Respiratory Therapis


Case management
1. To educate patient with knowledge of heart failure

2. To improve self-care at home
3. To decrease re-admission rate

Re-admision, why?
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…

-> Self-care is very important!


After discharge, patients “know”
1. Low salt diet
2. Fluid restriction

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.


SET UP
Education program “one to one” interaction

Goal
Rise awareness of heart failure


Strategy to activate motivation

1. Demonstrate a future for them
2. Help patients understand their disease severity
3. Turn the hospitalization time into a self-care training

course.


Educating self-care to HF patients
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.