1 phong ngua, dieu tri som suy tim HN LK 2020 (8h25 8h45)

Phòng ngừa và điều trị sớm suy tim

PGS. TS. Nguyễn Văn Trí
Đại học Y dược TP. HCM
P.Chủ tịch Hội Lão khoa Việt Nam
Chủ tịch Hội Lão khoa TP. HCM


ĐÁI THÁO ĐƯỜNG
MỆT NGỰC HOẶC KHÓ THỞ …..

SUY TIM ?
Cận lâm sàng gì?
ECG và siêu âm tim
Đủ loại trừ suy tim chưa ?
1


PHÂN LOẠI SUY TIM

2


2016 ESC Guidelines Heart Failure1

New Heart Failure terminology : HFrEF, HFmrEF, HFpEF
Type of HF

HFrEF

HFmrEF

HFpEF

1

Symptoms +/- Signs

Symptoms +/- Signs

Symptoms +/- Signs

2

LVEF < 40%

LVEF 40-49%

LVEF ≥ 50%

1.

1.

-

CRITERIA

3

2.

a.
b.

Changes ESC Guidelines
2012 ?

Elevated levels of natriuretic peptides (NTproBNP > 125 ng/L)
At least one additional criterion
Relevant structural heart disease (LVH
and/or LAE)
Diastolic dysfunction

40% instead of 35%

1 Ponikowski P. et al. (2016). European Heart Journal doi:10.1093/eurheartj/ehw128

New terminology

HF : heart failure
LAE : left atrial enlargement

2.
a.
b.

Elevated levels of natriuretic peptides (NTproBNP > 125 ng/L)
At least one additional criterion
Relevant structural heart disease (LVH and/or
LAE)
Diastolic dysfunction

Addition of natriuretic peptides in diagnostic criterion

LVEF : left ventricular ejection fraction
LVH : left ventricular hypertrophy

3


Đái tháo đường:

Nguy cơ độc lập dẫn đến suy tim
•

Diabetic 2 and 5 relative risk of
developing HF compared with nondiabetics2
• Approximately 45% diastolic heart failure
are in diabetic patients3

Potential mechanisms linking diabetes to HF5
Diabetes

Endothelial
dysfunction

Hemostatic
disorders
Microangiopathy

Myocardial

fibrosis

Abnormal
metabolism

CAD
Diabetic cardiomyopathy

HF
1.
2.
3.
4.
5.

Available at: Last accessed Dcember
2012
Van der Horst et al (2010). Neth Heart J 18(4):190-196
Çiftel S. et al., Diabetes Res Clin Pract, 96:179–86, 2012
Neuhold et al (2011). Eur J Clin Invest 41(12):1292-1298
Bauters et al (2003). Cardiovasc Diabetol 2:1-16

CAD: Coronary artery disease; HF: Heart failure

5


Các thuốc được chứng minh
kéo dài sự sống
trên Suy Tim PSTM giảm

ACE-I: ức chế men chuyển
ARBs: chẹn thụ thể angiotensin II
ARNI: ức chế thụ thể angiotensin neprilysin
6

TL: Ponikowski P. 2016 ESC Guideline for the diagnosis
and treatment of acute and chronic heart failure. Eur. H. J,
May 20, 2016


Dapagliflozin giảm 27% tần suất mới mắc Suy tim
trên phổ rộng bệnh nhân ĐTĐ từ nguy cơ TM thấp đến rất cao

4

HR

(95% CI)

p-value

0.73

(0.61, 0.88)

<0.001

Placebo (286 Events)

27%
DAPA 10 mg (212 Events)

Cumulative %

3

2

1

0

0

6

12

18

24

30

36

Months from Randomization

CI = confidence interval; DAPA = dapagliflozin; hHF = hospitalization for heart failure; HR = hazard ratio; N = number of patients.

In House Data, AstraZeneca Pharmaceuticals LP. CSR D1693C00001.

42

48

54

60


Thay đổi NT-proBNP
DAPA-HF: thay đổi NT-proBNP
tại tháng thứ 8

Baseline

EMPEROR: thay đổi NT-proBNP
tại tháng thứ 12


Vai trò của NT-proBNP trong suy tim

6


CHUỖI BỆNH LÝ TIM MẠCH
NMCT
TMCT

RL nhịp tim & RL chức
năng thất trái

ĐỘT
TỬ

XVĐM
Tái cấu trúc

Lớn thất trái

Tái cấu trúc

Phì đại thất trái
RL chức năng tâm trương

YTNC
Tăng HA
Bệnh ĐMV
Bệnh van tim
Béo phì
ĐTĐ
Bệnh thận

Suy tim
NYHA
Tử vong do
suy bơm

ĐỘT

TỬ

107


2017 ACC/AHA HF Guideline

8
Yancy, et. al. 2017 ACC/AHA/HFSA Heart Failure Focused Update


2017 ACC/AHA HF Guideline

9
Yancy, et. al. 2017 ACC/AHA/HFSA Heart Failure Focused Update


2017 ACC/AHA HF Guideline

Biomarkers Indications for Use

Biomarkers
COR

IIa

LOE

B-R

Recommendation
For patients at risk of developing HF,
natriuretic peptide biomarker–based
screening followed by team-based care,
including a cardiovascular specialist
optimizing GDMT, can be useful to
prevent the development of left
ventricular dysfunction (systolic or
diastolic) or new-onset HF.

GDMT stands for Guideline Determined Medical Therapy

Comment/
Rationale
NEW: New data
suggest that natriuretic
peptide biomarker
screening and early
intervention may
prevent HF.

10


NT-proBNP guided prevention for Diabetes

Martin Huelsmann et al. JACC 2013

11

PONTIAC trial: NT-proBNP guided prevention for Diabetes
Inclusion:
• Known type 2 diabetes for at least 6
months
• Age ≥18 years of age
• NT-proBNP concentrations >125 pg/ml

Exclusion:
• History of cardiac disease
• Signs of cardiac disease in the
electrocardiogram
• ST-T-wave abnormalities or a bundle
branch block
• Abnormal echocardiography ….

Allocation (n=300)

Guideline-based treatment (n=150)

Martin Huelsmann et al. JACC 2013

Intensified treatment (n=150)
1) up titration of RAS antagonists and beta-blocker to maximal
recommended dosage
2) Start ACEI if RAS antagonist or beta-blocker is not started
3) Increase dose of medication till NT-proBNP decreased by 50% or
below normal range or a tolerated dose achieved

2 years: hospitalization or death due to cardiac disease

12


PONTIAC trial: NT-proBNP guided prevention for Diabetes

Result

Martin Huelsmann et al. JACC 2013

Intensified group (n=150)

Control group (n=150)

3 deaths

5 deaths

None due to cardiac disease

3 out 5 due to cardiac disease

13


2017 ACC/AHA HF Guideline

14
Yancy, et. al. 2017 ACC/AHA/HFSA Heart Failure Focused Update

2017 ACC/AHA HF Guideline

15
Yancy, et. al. 2017 ACC/AHA/HFSA Heart Failure Focused Update


2017 ACC/AHA HF Guideline

Biomarkers
Biomarkers for Diagnosis
COR

I

LOE

A

Recommendation
In patients presenting with dyspnea,
measurement of natriuretic peptide
biomarkers is useful to support a diagnosis
or exclusion of HF.

Comment/
Rationale
MODIFIED: 2013 acute
and chronic
recommendations have

been combined into a
diagnosis section.

16


NT-proBNP predicts heart failure in diabetes

Objective: examined the individual and combined effect of NT-proBNP, high-sensitivity cardiac
troponin T (hs-cTnT), interleukin-6 (IL-6), and hs-CRP on the prediction of heart failure incidence or
progression in patients with type 2 diabetes.
Study design: case-cohort study, 11,140 patients with type 2 diabetes at high risk of cardiovascular
events who participated in Action in Diabetes and Vascular Disease: Preterax and DiamicronModified
Release Controlled Evaluation (ADVANCE) study
Toshiaki Ohkuma et al. Cardiac Stress and Inflammatory Markers as Predictors of Heart Failure in Patients With Type 2 Diabetes: The ADVANCE Trial.Diabetes Care Volume 40, September 2017

17


NT-proBNP predicts heart failure in diabetes
NT-proBNP showed the strongest association with heart failure

Toshiaki Ohkuma et al. Cardiac Stress and Inflammatory Markers as Predictors of Heart Failure in Patients With Type 2 Diabetes: The ADVANCE Trial.Diabetes Care Volume 40, September 2017

18


2017 ACC/AHA HF Guideline

Yancy, et. al. 2017 ACC/AHA/HFSA Heart Failure Focused Update

19


Kết luận:
▪ Suy tim sớm khi có khó thở, khoảng 45% phân suất tống máu bảo tồn
▪ NT-proBNP GIÚP chẩn đoán sớm suy tim đặc biệt trên bệnh nhân HFpEF
▪ Phòng ngừa và điều trị sớm suy tim cải thiện tiên lượng