Bài giảng Suy tim với chức năng tâm thu thất trái bảo tồn: Những vấn đề còn thách thức - TS.BS. Hoàng Văn Sỹ

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Bài giảng trình bày các nội dung: Tần suất suy tim với EF bảo tồn; Định nghĩa các loại suy tim theo ESC; Sinh bệnh học của HFpEF; Các cơ chế SBH trung ương và ngoại vi; Triệu chứng và dấu hiệu HFpEF;... Mời các bạn cùng tham khảo để nắm nội dung chi tiết.

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Nội dung Text: Bài giảng Suy tim với chức năng tâm thu thất trái bảo tồn: Những vấn đề còn thách thức - TS.BS. Hoàng Văn Sỹ

Suy tim với chức năng tâm thu thất trái bảo tồn Những vấn đề còn thách thức TS.BS. Hoàng Văn Sỹ Đại học Y Dược Tp. Hồ Chí Minh Khoa Nội Tim mạch BV Chợ Rẫy TP HCM 13/7/2019
Tần suất suy tim với EF bảo tồn (HFpEF) Khoảng ½ bệnh nhân suy tim có triệu chứng là suy suy tim EF bảo tồn In patients with clinical The proportion of incident Patients with HFpEF were HF, the prevalence of cases of HFpEF increased older and more likely to be HFpEF is estimated to be from 47.8% in 2000–2003 to female than those with approximately 50%1 52.3% in 2008–20102 HFrEF3a Vào 2020, ước đoán 65% suy tim nhập viện là suy tim EF bảo tồn4 aThe GWTG-HF registry was merged with claims from the U.S. Centers for Medicare and Medicaid Services (CMS) from January 1, 2005, through December 30, 2009, with 5 years of follow-up through the end of December 2014 HF, heart failure; HFrEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction. 1. Yancy CW et al. Circulation. 2013;128:e240-e327; 2. Gerber Y et al. JAMA Intern Med. 2015;175(6):996-1004; 3. Shah KS et al. J Am Coll Cardiol. 2017;70(20):2476-2486; 4. Oktay AA et al. Curr Heart Fail Rep. 2013; 10(4): doi:10.1007/s11897-013-0155-7.
Định nghĩa các loại suy tim theo ESC
1 Cơ chế bệnh sinh còn chưa rõ ? Suy tim EF bảo tồn là biểu hiện của 1 bệnh ? Hypertension and coronary artery disease are major risk factors for development of heart failure HFrEF is also called Age systolic HF, although LV enlargement Systolic Smoking dysfunction patients may also exhibit diastolic Dyslipidemia abnormalities HFrEF CAD/MI Hypertension HFpEF HFpEF is also called Obesity Diastolic diastolic HF, although Diabetes LV hypertrophy dysfunction most patients have evidence of both systolic and diastolic dysfunction Normal LV structure Subclinical and function LV remodeling LV dysfunction Clinical HF Years Years/months CAD, coronary artery disease; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; LV, left ventricular; MI, myocardial infarction. 1. Krum H, Gilbert RE. Lancet 2003;362:147–58; 2. Borlaug BA, Paulus WJ. Eur Heart J.2011;32:670–679.
Sinh bệnh học của HFpEF Các cơ chế SBH trung ương và ngoại vi Suy tim EF bảo tồn là biểu hiện của nhiều bệnh ? Pulmonary Pulmonary venous hypertension ± Impaired diffusion capacity • Heterogeneity of patient ± ‘Reactive’ arterial hypertension characteristics, organ- Peripheral Mechanisms system involvement and LV Diastolic number of Stiffening and Dysfunction pathophysiological Renal abnormalities suggest a Sodium retention LV Filling RV Filling multifactorial etiology Pressures Pressures in patients with HFpEF Endothelial dysfunction AF and Central RV Dysfunction • Subphenotypes in HFpEF LA Dysfunction Mechanisms are usually described according to the most Exercise Load dominant clinical Autonomic tolerance sensitivity Arterial dysfunction characteristics: Stiffening • HFpEF subphenotype LV Systolic Stiffening with PAH and RV and Dysfunction dysfunction has been well characterized and Coronary and systemic signifies advanced Skeletal muscle microvascular rarefaction Myopathy stage HF AF, atrial fibrillation, LA, left atria; LV, left ventricular; RV, right ventricular; HFpEF, heart failure with preserved ejection fraction; PAH, pulmonary arterial hypertension Zakeri R and Cowie MR. Heart 2018;104(5):377-384
Kiểu hình lâm sàng và bệnh lý đi kèm trong HFpEF Tăng huyết áp là yếu tố nguy cơ chính của HFpEF1 The most commonly encountered clinical Anemia COPD phenotypes of HFpEF include hypertension (identified as the core risk factor), aging, obesity, Atrial pulmonary hypertension, and CAD1,2 Aging Fibrillation Frailty These clinical phenotypes further share comorbid conditions that include atrial fibrillation, anemia, COPD, frailty, diabetes, obstructive sleep apnea, and CKD2 CAD Hypertension PH • Aging-related comorbid conditions include atrial fibrillation, anemia, COPD and frailty • Obesity-related comorbid conditions include diabetes, Obesity obstructive sleep apnea and CKD Diabetes CKD Defining clinical phenotypes could be essential for management of patients with HFpEF leading towards therapeutic progress Obstructive sleep apnea CAD, coronary artery disease, CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; HFpEF, heart failure with preserved ejection fraction; PH, pulmonary hypertension. 1. Yancy CW et al. Circulation. 2013;128:e240-e327. 2. Samson R. et al. J Am Heart Assoc. 2016;5(1):e002477. doi:10.1161/JAHA.115.002477.
2 Chẩn đoán HFpEF còn khó khăn ? Chẩn đoán suy tim EF bảo tồn dựa trên cơ chế hay dựa trên khía cạnh lâm sàng ? Dựa trên cơ chế1: Áp lực động mạch phổi bít 1. Zakeri R, Cowie MR. Heart2018;0:1–8. Kishan S, et al. JACC: HEART FAILURE. VOL.6,NO.8,2018 doi:10.1136/heartjnl-2016-310790
2 Chẩn đoán HFpEF còn khó khăn ? Chẩn đoán suy tim EF bảo tồn dựa trên cơ chế hay dựa trên khía cạnh lâm sàng ? Dựa trên lâm sàng1: ▪ Obese HFpEF/HFpEF with pulmonary vascular disease ▪ HFpEF with arterial stiffening ▪ HFpEF with endothelial dysfunction. 1. Zakeri R, Cowie MR. Heart2018;0:1–8. Kishan S, et al. JACC: HEART FAILURE. VOL.6,NO.8,2018 doi:10.1136/heartjnl-2016-310790
Triệu chứng và dấu hiệu HFpEF Triệu chứng tương tự suy tim EF giảm The main differences are that patients with HFpEF have lower rates of acute pulmonary edema and paroxysmal nocturnal dyspnea 120 P = 0.11 100 96.2 94.9 Patients (%) 80 P = 0.06 60 46.4 P = 0.007 42.5 P = 0.02 40 30.1 25 21.1 17.3 20 0 Dyspnea or shortness of breath Orthopnea Paroxysmal nocturnal dyspnea Acute pulmonary edema Reduced ejection fraction (50%) (n=880) HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; S3, third heart sound; S4, fourth heart sound. Bhatia RS, et al. N Engl J Med. 2006;355(3):260–269.
Triệu chứng và dấu hiệu HFpEF Triệu chứng tương tự suy tim EF giảm The main differences are that patients with HFpEF have lower rate of S3 heart sounds and chest radiographic signs and a higher rate of bilateral ankle edema P = 0.95 90 84.3 84.4 P
Lưu đồ chẩn đoán suy tim Siêu âm tim là bắt buộc để chẩn đoán suy tim 1. Ponikowski P, et al. Eur J Heart Fail. 2016 doi: 10.1002/ejhf.592
Đồng thuận ESC HFpEF: Điểm chẩn đoán và khả năng bị HFpEF •The ESC is developing an Heart Failure Association Pre-test probability, Echocardiography, Further advanced work-up, and Final etiology (HFA-PEFF) score •This was presented at the Heart Failure Congress in 2018, but at the time of this recording, the manuscript was not published Pieske B. ESC HFA Congress 2018. Abstract
Thang điểm mới chẩn đoán HFpEF: H2FPEF https://www.mdcalc.com/h2fpef-score-heart-failure-preserved-ejection-fraction#next-steps
Thang điểm mới chẩn đoán HFpEF: H2FPEF •The odds of HFpEF double for each 1 unit score increase •The maximum number of points is 9 and that correlates to a probability of HFpEF that goes above 95% Reddy YNV et al. Circulation 2018;138:861-870
3 HFpEF có tiên lượng xấu ? Suy tim EF bảo tồn có tiên lượng giống Suy tim EF giảm ? Overall mortality in HFpEF compared to HF hospitalization in HFpEF compared 80 other cardiovascular trials 80 to other cardiovascular trials 76 70 70 73 Other CV trials Rate per 1000 patient years CV trials Rate per 1000 patient years 69 HFpEF trials HFpEF trials 60 60 50 53 54 50 47.2 40 40 43 30 30 28.7 20 25.6 20 10 15.7 16.4 17.3 10 11.4 11 11.5 4.6 5.3 5.5 7.1 7.5 0 0 ACCORD ANBP-2 ACTION LIFE VALUE ALLHAT HYVET I-Preserve CHARM-P DIG-PEF ACTION HYVET ANBP-2 LIFE ACCORD VALUE ALLHAT I-PreserveCHARM-P DIG-PEF ACCORD [Action to Control Cardiovascular Risk in Diabetes], second Australian National Blood Pressure trial [ANBP-2], ACTION [A Coronary disease Trial Investigating Outcome with Nifedipine], Losartan Intervention for Endpoint reduction in hypertension [LIFE], VALUE [Valsartan Antihypertensive Long-term Use Evaluation], Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial [ALLHAT], and Hypertension in the Very Elderly Trial [HYVET]) and heart failure– preserved ejection fraction (HF-PEF) trials (DIG-PEF, CHARM-Preserved, and I-PRESERVE); CV, cardiovascular; HFpEF, Heart failure with preserved ejection fraction Campbell RT et al. J Am Coll Cardiol 2012;60:2349–56.
Tử vong ở bệnh nhân HFpEF sv HFrEF Tỉ lệ tử vong ở bệnh nhân HFpEF thấp hơn HFrEF Observational RCT A recent international, prospective, multi-ethnic cohort The overall mortality rate was consistently lower in the placebo arms of HFpEF trials study has shown that mortality rate in HFpEF is lower than (I-Preserve and CHARM-Preserve) versus HFrEF trials (CHARM-Added and CHARM- HFrEF (p=0.0013)1 Alternative)2 120 19% 115 100 111 Mortality rate during 2 year Rate per 1000 patient years 80 follow-up (%) 14% I-Preserve (n=4133) 12% 60 CHARM-Preserve (n=3023) 53 54 CHARM-Added (n=2548) 40 CHARM-Alternative (n=2028) 20 0 I-Preserve CHARM-Preserve CHARM-Added CHARM-Alternative HFpEF (n=574) HFmrEF (n=256) HFrEF (n=1209) HFpEF trials HFrEF trials HFmrEF, Heart Failure with mid-range ejection fraction; HFpEF, Heart failure with preserved ejection fraction; HFrEF, Heart failure with reduced ejection fraction. 1. Lam CSP et al. Eur Heart J. 2018;39(20):1770-1780. 2. Campbell RT et al. J Am Coll Cardiol 2012;60:2349–56.
Xu hướng nhập viện ở bệnh nhân suy tim EF bảo tồn qua nc quan sát High rate of HF hospitalizations in HFpEF and HFrEF, however a higher rate of non-HF readmissions is observed among patients with HFpEF HF and CV readmissions in According to 5-year outcomes analysis of patients patients with HFpEF1* in the GWTG-HF registry, a lower rate of HF readmissions was observed in HFpEF than HFrEF2 100 10% 84 82.2 80 readmitted within 30-days Event rate (%) of hospital discharge 60 48.5 40.5 40 37% 20 readmitted within 1 year 0 of hospital discharge All-cause readmissions HF readmissions HFpEF (n=18299) HFrEF (n=18398) *Study cohort included 40239 patients from 220 hospital sites in the GWTG-HF registry between January 1, 2005, and December 30, 2011. Patients in the GWTG-HF registry were hospitalized for acute decompensated heart failure. HFrEF (EF
4 Điều trị HFpEF chưa xác định ? Mục tiêu điều trị HFpEF Current management and unmet treatment needs HFpEF patients areoften: • Elderly • Living with co-morbidities (e.g. hypertension, diabetes) Situation • Highly symptomaticand have poor QoL • Management of co-morbidities • Alleviate symptoms and improve well-being Goals • Screen for comorbidities and treat to improve symptoms if present Treatment • Diuretics for congestion to alleviate symptoms and signs HFpEF=Heart failure with preserved ejection fraction; QoL=Quality of life Ponikowski P et al. Eur Heart J 2016;37(27):2129–200
Hướng dẫn ACC/AHA/HFSA về HFpEF
Nhưng….... HFpE F No treatment has yet been shown, convincingly, to reduce morbidity or mortality in patients with HFpEF or HFmrEF.1 HF=Heart failure; HFmrEF=Heart failure with mid-range ejection fraction; HFpEF=Heart failure with preserved ejection fraction 1. Ponikowski P et al. Eur Heart J 2016;37(27):2129–200