Bài giảng Suy tim mạn góc nhìn từ ACC 2017 - PGS.TS Châu Ngọc Hoa

Bài giảng với các nội dung: hai liệu pháp dược lý mới được FDA chấp thuận cho bệnh suy tim, dòng thời gian phê duyệt Ivabradine, thời gian chuẩn độ như được xác định trong các thử nghiệm mang tính bước ngoặt, lý do không đạt được liều đích, hiệu quả điều trị của Ivabradine theo huyết áp...
Nội dung trích xuất từ tài liệu:
Bài giảng Suy tim mạn góc nhìn từ ACC 2017 - PGS.TS Châu Ngọc HoaSuy tim mạn:GÓC NHÌN TỪ ACC 2017 PGS TS Châu Ngọc Hoa Bộ môn Nội ĐHYD Tp HCMACC Focused update on HF, 2017Two New Pharmacological TherapiesApproved by FDA for Heart Failure• Ivabradine (April 15, 2015)• Sacubitril/Valsartan (July 7, 2015)WHO, WHEN AND WHY ADDON IVABRADINE Ivabradine approval timeline • 2005 approved in EU for angina • 2012 approved in EU for heart failure • 2015 approved in US for heart failure to reduce the risk for hospitalization for worsening heart failure in patients withstable, symptomatic chronic heart failure with LVEF ≤35%, who are in sinus rhythmwith a resting heart rate of ≥70 beats per minute (bpm) and are taking maximallytolerated doses of beta-blockers or have a contraindication to beta-blockers.Ivabradine Blocks If channel Slows heart rate Few if any other CV effects SHIFT Trial > 6500 HF patients (NYHA II-IV) LVEF < 35% Resting HR > 70 BPM Primary endpoint: composite of CV death/HF hospitalization On maximally tolerated beta-blockerSHIFT: primary outcome CV death or hospitalization for HF (%) 40 HR= 0.82 pSHIFT: HF hospitalization Hospitalization for HF (%) 30 Placebo HR= 0.74 20 10 Months 6 12 18 24 30 Swedberg K, et al. Lancet. 2010;376:875-885.Ivabradine in HF Up-titrate beta blocker dose as much as possible Add on therapy to beta blocker; not replacement Does not lower blood pressure Contraindicated in atrial fibrillation Benefit greater in patients with higher baseline heart rateTarget doses as defined in the ESC guidelines Startingdose(mg) Targetdose(mg) ACEI Enalapril 2.5b.i.d 10-20b.i.d Lisinopril 2.5-5.0o.d 20-35o.d Ramipril 2.5o.d 5b.i.d Beta-blocker Bisoprolol 1.25o.d 10o.d Carvedilol 3.125b.i.d 25-50b.i.d Metoprololsuccinate 12.5/25o.d 200o.d MRA Eplerenone 25o.d 50o.d Spironolactone 25o.d 25-50o.d IfInhibitor Ivabradine 5b.i.d 7.5b.i.d Can we reach and maintain „target” dosein „real-life” elderly HF patients with comorbidities ?CIBIS-ELD – 883 elderly HF patients;The primary endpoint: tolerability, defined as reaching and maintaining guideline-recommended target doses after 12 weeks treatment. Dungen HD, et al. Eur J Heart Fail. 2011:13:670–680. Up-titration period as defined in the landmark trials Trials Targetdose (mg) Time to reach target/max tolerated dose ACEI Enalapril SOLVD 10b.i.d Notspecified Lisinopril ATLAS 35o.d 4weeks Beta-blocker Bisoprolol CIBISII 10o.d 11weeks Carvedilol COPERNICUS 25b.i.d 6weeks Metoprololsuccinate MERITHF 200o.d 6weeks Nebivolol SENIORS 10o.d 6weeks MRA Eplerenone EMPHASIS-HF 50o.d 4weeks IfInhibitor Ivabradine SHIFT 7.5b.i.d 2weeks 1- The SOLVD Investigators. N Engl J Med.1991;325:293-302. 2- Packer M, et al. Circulation. 1999;100:2312-2318. 3- CIBIS-II study group.Lancet.1999;353:9-13. 4- Packer M, et al. Circ. 2002;106:2194-2199. 5- Merit-HF study group. Lancet.1999;353:2001- 2007. 6- Zannad F, et al. N Engl J Med. 2011:364:11-21. 7- Swedberg K, et al. . Lancet 2010;376: 875-885. Uptitration target in stable HF patients ACEIs Beta-blockers 4 weeks 6 weeks Dose MRAsIvabradine 4 weeks2 weeks .Reasons for non-reaching target doseCIBIS-ELD: RCT aimed to reach guideline-recommended target doses883 HF patients, NYHA II-IV, >65 y, no contraindication or intolerance to BB Dungen HD, et al. Eur J Heart Fail. 2011:13:670–680.Yes but …My Patient …- is too old- has low ...