6.phamviettuan.md

8/4/2019 6.PHAMVIETTUAN.MD

http://slidepdf.com/reader/full/6phamviettuanmd 1/35

DEMA-CVN.COMGIỚ I THIỆU

CÁC ĐỀ TÀI BÁO CÁO TẠI HỘINGHỊ TIM MẠCH MIỀN TRUNG- TÂY NGUYÊN MỞ R ỘNG LẦN THỨ VI TẠIBUÔN MA THUỘ T THÁNG 8 NĂM 2011



Heart Failure andcardiovascular diseases at

Vietnam Heart Institute

Pham Viet Tuan, MD; Nguyen Lan Viet, MD, PhD;Nguyen Thi Thu Hoai, MD, PhD; Pham Gia Khai,

MD, PhD

Vietnam National Heart Institute

VNHI

The 11th Central Vietnam Cardiology Congress

Buon ma thuot city - Daklak



Background

Cardiovascular disease is a major publichealth problem facing the Vietnamese

community

Heart failure (of both rheumatic and

ischaemic origin) is a major cause of: hospitalisation

cardiovascular morbidity and mortality



VNHI

NYHA Functional Class II III IV

Annual Mortality (%) 5 - 15 20 - 50 30 -70Sudden Death (%) 50 - 80 30 - 50 5 - 30

ImproveSymptoms

ReduceSCD

Sudden Death by Severity of Heart Failure Symptoms*

* Uretsky B, Sheahan G. J Am Coll Cardiol 1997;30:1589-97

CHF is a Deadly Disease



Pathogenesis of Heart Failure

A Complex Cascade

Adaptation

LV Dysfunction

PrimaryCardiac Damage

Sudden –MI

• Myocyte hypertrophy

• Neurohormonalactivation

Maladaptation• Dilatation

• Alterations in gene programs

Gradual –Hypertension

VNHI



Preload

S t r

o k e v o l u m

e

Lowoutput

Pulmonarycongestion

Frank-Starling CurveVNHI



CardiorenalDigitalis and

diuretic to

perfuse kidneys

HemodynamicVasodilators or

positive inotropes

to relieve ventricularwall stress

NeurohormonalACE inhibitors,

beta blockers, and

other agents to block

neurohormonalactivation

1940s 1960s 1970s 1990s–2000

Pepper, Arch Intern Med 1999.

Evolving Models of Heart Failure

GeneticTherapies to

modulate

apoptosis,

fibrosis,

remodeling,arryhthmic

substrates



Definitions of Heart Failure

Systolic Heart Failure

Clinical signs andsymptoms - dyspnea,edema, fatigue

CXR - pulmonarycongestion

Typical clinicalresponse to treatment

Reduced systolicfunction - EF < 0.50

Diastolic Heart Failure

Clinical signs andsymptoms - dyspnea,edema, fatigue

CXR - pulmonarycongestion

Typical clinical

response to treatment LV EF > 0.50

Diastolic dysfunctionby cath LVEDP

Proposed Definitions

Circulation 2000;101:2118-2121



ACE-I

OrARB

Beta

Blocker

Aldosterone

Blocker

DiureticDigoxin

Statin A/C

Device

TherapyAnti-

Arrhythmic VNHI



Sinusnode

AVnode

Intraventricular Activation

Organized ventricularactivation sequence

Coordinated septal andfreewall contraction

Improved pumping

efficiency

Ventricular Resynchronization

Stimulationtherapy

Conductionblock

Kass D. New dimensions in device-based therapy for heart failure –mechanisms of

stimulation for heart failure. Heart Failure Society of America 1999.



VNHI

At present, there are no data availableon the trends of heart failure and othercardiovascular diseases in Vietnam

The present study attempts to address

this important issue in a hospital-basedsurvey



AimDescribes contemporary trends in hospitalization

for heart failure in Vietnam Heart Institute (VNHI)

VNHI



VNHIStudy Design

Retrospective

Cross-sectional

Hospital-based

Survey



Method Data from patient case records; 2003 – 2007

Coded up routinely to diagnosis at the time ofhospital discharge according to ICD-10

Retrospectively identified all hospitalizationsoccurring within VNHI where heart failure wascoded.

VNHI



VNHI

Sample Population Characteristic:

45176 subjects51.3% men and 48.7% women

Mean age: 51.3 18.4 years



VNHI

19.8%Heart Failure

Others

8958 patients (19.8%) were coded with

a diagnosis of heart failure



0.9%

1.6%

2.4%

2.4%

3.8%

4.6%

8.7%

18.3%

19.8%

20.2%

20.4%

30.8%

0 5 10 15 20 25 30 35

Rheumatic heart disease

Hypertension

Arrhythmia

Heart failure

Ischemic heart disease

Congenital heart disease

Cerebrovascular disease

Cardiomyopathies

PAD

Pericardial disease

DVT

Endocarditis

Heart failure and cardiovascular diseases at VNHI



VNHI

0.7% 0.7%

8.7%

10.6%

23.0%

31.5%

10.9% 11.3%

1.0%1.7%

0

5

10

15

20

25

30

35

< 20 20-39 40-59 60-79≥ 80

Male

Female

%

Age

Hospitalizations for heart failure in age-groupsand sex-groups



VNHI

0

1000

2000

3000

4000

5000

6000

7000

8000

HF Ischemic heart

disease

Congenital heart

desease

Arrhythmia

< 20

20-39

40-59

60-79

≥ 80

Hypertension Rheumaticheart disease

Pericardialdisease

Cardiomyopathies

Heart failure and cardiovascular diseases inage-groups



VNHI

1416

17661900 1914

1962

0

500

1000

1500

2000

Numbers of HF patients

TRENDS OF HEART FAILURE

2003 2004 2005 2006 2007

T d f b l t b f h t f il



196219141900

1766

1416

0

500

1000

1500

2000

2500

3000

3500

1 2 3 4 5

Heart Failure Hypertension Ischemic heart disease

Rheumatic heart disease Congenital heart desease Pericardial disease

Arrhythmia Cardiomyopathies Endocarditis Cerebrovascular disease PAD DVT

Trends of absolute numbers of heart failureand CVD patients

2003 2004 2005 2006 2007



VNHI

A decline in the proportion of valvular-relateddisease

36.7%33.4%

31.5%

27.8%

27.0%

0

10

20

30

40

2003 2004 2005 2006 2007

%



An increase in the proportion of ischemicdisease

11.2%

13.5%

18.8%

20.8%

24.0%

0

5

10

15

20

25%

2003 2004 2005 2006 2007



VNHI

Heart Failure in Children

Arrhythmia Congenital Rheumatic



0

200

400

600

8001000

1200

1400

1600

J a n F e b

M

a r c h

A p r i l

M a y J u

n e J u l y

A

u g u s t

S e p t O c

t N o

v D e

c

Heart Failure

Hypertension

Ischemic

heart disease

Rheumatic

heart disease

HF and CVD hospitalizations by months



CHF Treatment

Commonly Utilized Therapies

Digitalis - Reduce CHF Symptoms

Diuretics - Best for treating edema andpulmonary congestion

Inexpensive

Effective Widely available

VNHI



Hints on Digitalis and Diuretics

Diuretics

No reduction inmortality

Reduce CHFsymptoms

May be used

intermittently May paradoxically

activate the RAAS

Digoxin

No reduction inmortality

Reduce CHFsymptoms

Withdrawl mayprecipitate CHF

Narrow therapeuticwindow compared totoxicity window

VNHI

P MI D Th



Post MI Drug Therapy

Clopidogrel

Digoxin

LMWHeparin

CP943451-2



Effect of b-Blockade on All-Cause Mortality

0 0.25 0.5 0.75 1 1.25 1.5 1.75 2

Relative risk and 95% confidence intervals

CIBIS-II: 1.3 yearsplacebo 228/1320 (17%); bisoprolol 156/1327 (12%P=.0001

MERIT-HF: 12 months placebo217/2001 (11%); metoprolol 145/1990 (7%)

P=.006

CIBIS-I: 1.9 yearsplacebo 67/321 (20%); bisoprolol 53/320 (16%)

P=.22

US Carvedilol Trials: 7.6 monthsplacebo 31/398 (8%); carvedilol 22/696 (3%)P=.001

The magnitude of effect with Carvedilol is much greater than that of Metoprolol and Bisoprolol



Beta Blockers in CHF- Further thoughts

Recently the CAPRICORN trial demonstratedcarvedilol was superior to metoprolol, 6%absolute risk reduction

Caution: Val-HEFT suggested use of BB withAce and ARB might increase mortality –

Hypotension appeared to be the mechanism



11.2

12.512.412.613.5

0

2

4

6

8

10

12

14

16

2003 2004 2005 2006 2007

Number of day

Length of stay of in-hospital HF patientsin Vietnam



Heart failure is the common cause of hospitalizationin Vietnam.

The number of HF hospitalized patients increased

in recent years.

As the costs of medical care continue to rise,

decreasing hospitalizations among patients with HF is

critically important.

Conclusion



Strategies aiming to reduce hospitalization must

include the identification and management of

comorbid conditions in addition to addressing HF

manifestations.

Take home message



Thanks for your

attention!

6.phamviettuan.md

Documents