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2016 內科醫學會年會
心衰竭治療的最新進展
心衰竭治療的需求與重要性回顧
(REVIEW OF UNMET NEEDS IN THE
TREATMENT OF HEART FAILURE)
殷偉賢
振興醫院 心臟內科
On behalf of the Study Group of the Registry of
Heart Failure with Reduced Ejection Fraction,
Taiwan Society of Cardiology
 The present guideline represents the commitment of the Taiwan Society of
Cardiology to recognize heart failure as a major health care challenge and
to provide advices and resources for clinicians and related health care
providers.
 With guideline recommendations, we hope that the management of heart
failure can be improved.
 Current recommendations from the guidelines on the diagnosis and treatment
of chronic heart failure closely resemble those contained in guidelines in
the western world.
Heart failure in Taiwan: Prevalence
• Chin-Shan community cardiovascular cohort, 2660
subjects (1991-1992)
• The prevalence of HF was 5.5% [HFpEF 4.6%; HFrEF
(LVEF<55%) 0.9%]
70.8%
51.5%
Huang et al. EJHF 2007;9:587-593
Incidence of HF hospitalization, 2005
Incidence:
271.2/100,000
9.7%
81.1%
Tseng et al. JAGS 2010;58
Heart failure in Taiwan: length of stay
More than 20,000 patients admitted due to HF in 2014
Mean length of stay: 11.9 days
Heart failure in Taiwan: outcomes
Chronic
decline
Cardiac
function
Hospitalizations
Disease progression
Wang et al. Acta Cardiol Sin 2012;28:161–95
Taiwan Society of Cardiology
Registry on Heart Failure with
Reduced Ejection Fraction
• Study population:
– Patients with systolic HF (LVEF≦40%) and
admitted for acute HF, pre-existed or new
onset, during the enrollment period.
• Follow-up:
– Follow-up status was collected at the 6th
month and the 12th month after enrollment.
Total patient numbers 1,509
234 (15.4%)
700 (46.4%)
108 (7.2%)
Total 21
hospitals
157 (10.4%)
12 (0.8%)
298 (19.8%)
Study period:
07/01/2013 to 12/31/2015
Characteristics at Admission
LVEF (2-D Echo)
29 ± 9 %
N=1,509
Age
64 ±16 years
Male
1093 (72.5 %)
Day of hospitalization
median 8 days (IQR= 5-15 days)
Stay in ICU
497 (33.0 %) (median 4 days)
Admission SBP
131 ± 28 mmHg
Admission DBP
81 ± 20 mmHg
Admission HR
93 ± 22 bpm
Admission weight
67.4 ±17.0 kg
BMI
25.4 ±6.5
Admission NYHA Fc I / II / III / IV
0.7 / 11.1 / 50.3 / 37.8 %
Precipitating Causes of
Decompensated HF
診斷心衰病因 找尋誘發因素
I IIa IIb III
ACS precipitating acute HF decompensation should be
急性冠心病應及早診治
promptly identified
by ECG and serum biomarkers
including cardiac troponin testing, and treated optimally as
appropriate to the overall condition and prognosis of the
patient.
I IIa IIb III
Common precipitating factors for acute HF should be
急性心衰常見誘因應及早發現處理
considered during initial evaluation, as recognition of these
conditions is critical to guide appropriate therapy.
Primary Etiology of HF
44.1%
Ischemic
32.9%
Dilated
7.9%
7.1%
Hypertensive
Valvular
Possible Precipitating Factors
N=1,509
Acute coronary syndrome / myocardial ischemia
31.3 %
Non-compliance / behavioral / drugs
24.6 %
NSAID use
0.1 %
Rapid atrial fibrillation
16.4 %
Ventricular arrhythmia
5.2 %
Bradyarrhythmias
0.9 %
Uncontrolled hypertension
4.8 %
Infection
17.0 %
Renal dysfunction
14.5 %
Anemia
3.3 %
Asthma / COPD exacerbation
3.3 %
Signs of
hypoperfusion
Clinical presentations
Hypotension
9.9%
Engorged jugular vein
23.9%
Confusion/Somnolence
Pulmonary rales
5.1%
63.5%
Pleural effusion
28.8%
Peripheral edema
49.3%
S3 Gallop
18.2%
Peripheral
hypoperfusion
14.1%
wet and warm
Dry and cold
WET & COLD
Specific Management during admission
Duration (days)
Dobutamine
307 (20.4%)
8.8 ± 10.7
Dopamine
281 (18.6%)
5.9 ± 7.6
Levosimendan
12 (0.8%)
Milrinone
17 (1.1%)
9.2 ± 13.5
Nitroglycerin
408 (27.1%)
3.0 ± 2.1
IV Diuretics
943 (62.6%)
5.8 ± 7.6
New implant CIED
55 (3.6%)
22 PPM, 15 ICD, 12 CRT-P, 6 CRT-D
Ventilator support
195 (12.9%)
6.9 ± 11.3
IABP
41 (2.7%)
6.3 ± 9.2
ECMO
7 (0.5%)
12.9 ± 17.4
CABG
35 (2.3%)
-
Valvular surgery
17 (1.1%)
-
SAVR surgery
9 (0.6%)
-
40.9%
7.3 ± 10.4
Patient numbers
Timeframe
Age (yrs)
Male
Ischemic etiology (%)
Left Ventricular Systolic Dysfunction
Left Ventricular Ejection Fraction (%)
Hypertension
Hyperlipidemia
Coronary Artery Disease
Prior Myocardial Infarction
Atrial Fibrillation
Diabetes Mellitus
Chronic Kidney Disease
Chronic Obstructive Pulmonary Disease
Heart rate (bpm)
Systolic Blood Pressure (mmHg)
Sodium (mEq/L)
Creatinine (mg/dL)
BNP (pg/mL)
Hemoglobin (g/dL)
ADHERE
EHFS II
ATTEND
TSOCHFrEF
105,388
2001-2004
3,580
2004-2005
4,842
2007-2011
1,509
2013-2015
72 ± 14
70 ± 13
73 ± 14
64 ± 16
48
54
58
72
-
54
31
44
63
66
53
100
34 ± 16
38 ± 15
-
29 ± 9
73
63
69
35
37
-
37
34
57
54
-
42
31
-
-
25
31
39
40
26
44
33
34
44
30
17
-
32
31
19
10
11
-
95 (77-114)
99 ± 29
93 ± 22
144 ± 33
135 (110-160)
145 ± 37
131 ± 28
-
-
139 ± 4
138 ± 5
1.8 ± 1.6
-
1.4 ± 1.6
1.9 ± 1.8
840 (430-1,730)
-
707 (362-1,284)
1250 (554-2,487)
-
-
12.0 ± 2.6
12.9 ± 2.4
Intravenous drugs and
interventional procedures
Median Length of Stay
8 days (IQR 5~15)
In-Hospital Mortality
In-Hospital Mortality (%)
*
2.4%
GDMT at discharge
61.6%
59.7%
49.0%
Why NOT using RAAS inhibitors?
ACEI/ARB yes
ACEI/ARB no
P value
Patient numbers
900 (61.6%)
560 (38.4%)
Age
61.4 ± 16.4
67.3 ± 14.9
<0.001
Male
74.2%
69.5%
0.048
Discharge SBP
120.3 ± 18.8
118.5 ± 18.0
0.079
Discharge DBP
73.0 ± 13.5
70.6 ± 12.5
<0.001
Discharge SBP ≤ 120
50.8%
55.7%
<0.001
Discharge HR
80.4 ± 14.9
80.3 ± 15.0
0.844
Discharge BUN
28.7 ± 19.8
41.0 ± 26.8
<0.001
Discharge Cr
1.5 ± 1.6
2.2 ± 4.3
<0.001
Cr ≥ 2.5
9.2%
26.3%
<0.001
K
4.0 ± 0.6
4.1 ± 0.7
0.002
K ≥ 5.5
5.0%
10.9%
<0.001
Why NOT using beta-blocker?
Beta-blocker +
Beta-blocker -
P value
Patient numbers
871 (59.7%)
589 (40.3%)
Age
61.4 ± 16.3
67.0 ± 15.1
<0.001
Male
72.8%
71.8%
0.683
Admission SBP
134.0 ± 28.6
127.6 ± 24.8
<0.001
Admission DBP
83.0 ± 20.2
78.1 ± 17.9
<0.001
Admission HR
94.0 ± 23.1
91.3 ± 20.9
0.022
Discharge SBP
120.3 ± 18.6
118.6 ± 18.3
0.073
Discharge DBP
73.1 ± 13.5
70.6 ± 12.6
<0.001
Discharge HR
79.2 ± 14.7
82.1 ± 15.2
<0.001
Discharge BUN
33.7 ± 24.5
33.6 ± 22.2
0.993
Discharge Cr
1.9 ± 3.7
1.6 ± 1.2
0.082
Asthma/COPD
7.3%
16.0%
<0.001
Why NOT using aldosterone blockers?
MRA +
MRA-
Patient numbers
716 (49.0%)
745 (51.0%)
Age
60.3 ± 17.0
67.0 ± 14.5
<0.001
Male
75.1%
69.8%
0.022
Discharge SBP
116.7 ± 18.1
122.4 ± 18.5
<0.001
Discharge DBP
72.4 ± 13.8
71.8 ± 12.6
0.357
Discharge HR
81.1 ± 15.3
80.0 ± 14.6
0.044
Discharge BUN
27.2 ± 16.0
39.6 ± 27.7
<0.001
Discharge Cr
1.3 ± 0.7
2.3 ± 4.1
<0.001
Cr ≥ 2.5
6.4%
24.7%
<0.001
K
4.0 ± 0.6 Contra-indicated 4.1 ± 0.7
P value
0.001
K ≥ 5.5
5.5%
9.0%
0.055
LVEF
25.8 ±8.5
30.1 ±8.1
<0.001
LVEF ≥ 35% and / or discharge
NYHA Fc I
33.9%
43.3%
<0.001
Use of beta-blocker
59.9%
59.5%
0.877
Use of ACEI/ARB
67.1%
56.4%
<0.001
Not-indicated
Taiwan Systolic Heart Failure
Registry: follow-up at 1 year
TSOC-HFrEF outcomes
10.5%
15.9%
 1-yr Re-hospitalization rates for HF: 38.5% (vs. 24.8% in ESC-HF)
 At 1-yr, only 46.4% were free from death, hospitalization for HF,
LVAD or HTX (vs. 64.2% in ESC-HF)
OPTIMIZ EHFSE-HF
2
IN-HF
JCARECARD
KorHF
Hong
Kong HF
TSOCHFrEF
Baseline Characteristics
Year of enrollment
2003~04
~2005
2007~09
2004~05
2004~09
2005~12
2013~15
Patient numbers, n
20,118
2,981
1,292
847
1,527
383
1,509
Age, y/o
70.4
71.7
71
66.6
69.1
72.2
63.9
Male
62%
61.6%
66.4%
72.2%
55.9%
59.8%
72.4%
BMI kg/m2
NA
26.8
27.4
22.7
23.2
NA
25.2
LVEF, %
24.3
38.4
31.6
27
28.7
NA
28.5
Hypertension
66%
62.1%
55.6%
50.4%
42.0%
60.3%
34.5%
Diabetes mellitus
39%
33.1%
41.0%
33.3%
31.4%
36.0%
43.6%
NA
16.5%
34.0%
10.4%
7.3%
8.9%
31.5%
Coronary artery dz
54%
53.6%
NA
39.8%
40.1%
34.2%
41.8%
Atrial fibrillation
28%
38.6%
32.7%
24.5%
20.8%
31.3%
26.0%
Comorbid Conditions
Chronic renal failure
Guideline-Directed Medication Therapy at Discharge
ACEI or ARB
NA
80.2%
NA
83.5%
68.0%
68.6%
62.1%
ACEI
62%
71.1%
57.3%
44.2%
45.6%
NA
27.5%
ARB
11%
10.4%
20.5%
45.9%
24.5%
NA
34.6%
Beta-blocker
73%
61.8%
67.1%
65.9%
40.9%
48.2%
59.6%
MRA
18%
47.3%
60.4%
45.9%
37.5%
12.2%
49.0%
60±90 d
1 year
1 year
1 year
1 year
1 year
1 year
All-cause mortality
9.8%
21.9%
24.4%
8.9%
9.2%
19.5%
15.9%
Re-hospitalization
29.9%
NA
30.1%
23.7%
9.8%
NA
38.5%
Outcomes after discharge
Follow-up period
Trends in oral medication over time
Discharge
Medication
6-months
medication
12-months
medication
ACEI
27.5 %
17.5%
16.8%
ARB
34.6 %
39.3%
40.7%
ACEI or ARB
62.1 %
56.8%
57.5%
Beta-blocker
59.6 %
67.3%
66.3%
MRA
49.0%
43.9%
40.8%
Diuretics
82.2%
76.5%
75.9%
Digoxin
25.9 %
25.5%
24.0%
Anti-platelet
59.4 %
58.0%
57.3%
Anti-coagulant
21.3 %
21.1%
23.7%
Nitrates
36.4 %
32.3%
32.2%
Hydralazine
4.9 %
4.6%
4.2%
Anti-arrhythmic agents
15.7 %
16.0%
14.8%
GDMT: Prescription & Outcomes
64.4%
35.6%
20.6%
10.7%
18.8%
All 3 GDMTs
7.4%
12.3%
8.7%
0 GDMTs
11.6%
10.0%
Multivariate analysis for
all-cause morality
Hazard
ratio
1.01
95% CI
P Value
1.00-1.02
0.007
Body Mass Index
Fc III/IV Symptoms
at Discharge
0.95
0.91-0.99
0.023
1.88
1.28-2.77
0.001
Hypothyroidism
Hyponatremia
GDMT usage≤1
3.97
1.86
1.59
1.96-8.05
1.27-2.72
1.07-2.38
<0.001
0.001
0.023
Length of Stay
Survival of HF patients according to
the number of risk factors
2.9%
13.1%
11.2%
LOS ≧ 8 days
BMI ≤ 22.4 kg/m2
25.2%
Na ≤ 135 mEq/L
NYHA Fc III/IV at
discharge
Hypothyroidism
GDMT ≤ 1 type
41.2%
2016
European
HF
guidelines
Novel oral anti-HF medications
Ivabradine:
specific and
selective
inhibitor of the
If ion Channel
Novel oral anti-HF medications
Angiotensin Receptor
Neprilysin Inhibitor (ARNI)
New pharmaceutical targets in HF
Patient inertia
Diuretics
Inotropes,
vasodilators
ACEi/ARB, β-blockers,
MRA, Neprilysin
inhibitor
CRT, CCM, MV
repair
Patient inertia
Diuretics
Inotropes,
vasodilators
ACEi/ARB, β-blockers,
MRA, Neprilysin
inhibitor
CRT, CCM, MV
repair
Physician inertia
Multi-disciplinary team approach for the
management of HF patients
9.1%
10.9%
20.6%
23.4%
Single center (Chang Gung Memorial Hospital, Keelung), 349 patients
Multidisciplinary disease management program for HF improved outcomes
Mao et al. J Cardiovasc Med 2015;16:616–624
Post-acute care
Conclusions
•
•
•
•
•
Although in-hospital mortality rate was low (2.4%), mortality and
readmission rates were still high at 1-yr follow-up in the HFrEF
Registry of TSOC, reflecting unmet needs in caring patients with HF.
Evidence-based guideline directed diagnosis, evaluation and
therapy should be the mainstay for all patients with HF.
Effective implementation of guideline-directed best quality care
reduces mortality, improves QOL and preserves health care
resources.
How to overcome the possible underlying obstacles for the
underperformance of HF treatment in Taiwan, including unwary
about the impact of HF and exaggerated concerns over treatment
risks and side-effects, etc., are importance.
Multiple disciplinary team should be applied in order to improve the
quality of heart failure care