Bài giảng Suy tim với chức năng tâm thu thất trái bảo tồn

Nội dung text: Bài giảng Suy tim với chức năng tâm thu thất trái bảo tồn

1. 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
2. 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 1 3a approximately 50% 52.3% in 2008–20102 HFrEF 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.
3. Định nghĩa các loại suy tim theo ESC
4. 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 patients may also Smoking dysfunction exhibit diastolic Dyslipidemia HFrEF abnormalities 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.
5. 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 system involvement and Mechanisms 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 Autonomic tolerance sensitivity dominant clinical Arterial dysfunction characteristics: Stiffening • HFpEF subphenotype LV Systolic Stiffening with PAH and RV and Dysfunction dysfunction has been well characterized and Coronary and systemic Skeletal muscle signifies advanced microvascular rarefaction stage HF Myopathy 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
6. 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, pulmonary hypertension, and CAD1,2 Atrial Fibrillation Aging 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.
7. 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
8. 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
9. 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 80 P = 0.06 Patients (%) Patients 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.
10. 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<0.001 80 P = 0.02 66 P = 0.03 70 61.3 56.6 57.5 P = 0.003 60 51.8 47 45.6 50 40.9 Patients (%) 40 30 P = 0.002 20 12.5 8.4 10 0 Crackles or rales on Bilateral ankle edema Neck-Vein distension Pulmonary edema Pleural effusion Presence of S3 lung examination 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.