DEMA-CVN.

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GII THIU

CC TI BO CO TI HI NGH TIM MCH MIN TRUNG- TY NGUYN M RNG LN TH VI TI BUN MA THUT THNG 8 NM 2011

The 11th Central Vietnam Cardiology Congress

Buon ma thuot city - Daklak

Heart Failure and cardiovascular diseases at Vietnam Heart Institute

VNHI

Pham Viet Tuan, MD; Nguyen Lan Viet, MD, PhD; Nguyen Thi Thu Hoai, MD, PhD; Pham Gia Khai, MD, PhD Vietnam National Heart Institute

Background

Cardiovascular disease is a major public health problem facing the Vietnamese community
Heart failure (of both rheumatic and ischaemic origin) is a major cause of: hospitalisation cardiovascular morbidity and mortality

CHF is a Deadly Disease

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Sudden Death by Severity of Heart Failure Symptoms*

NYHA Functional Class Annual Mortality (%) Sudden Death (%) II III IV 5 - 15 20 - 50 30 -70 50 - 80 30 - 50 5 - 30
Improve Symptoms

Reduce SCD

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

Pathogenesis of Heart Failure

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A Complex Cascade
Primary Cardiac Damage SuddenMI GradualHypertension

LV Dysfunction

Myocyte hypertrophy Neurohormonal activation

Adaptation

Dilatation Alterations in gene programs

Maladaptation

Frank-Starling Curve
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Stroke volume

Low output

Pulmonary congestion

Preload

Evolving Models of Heart Failure

Genetic
modulate ACE inhibitors, Cardiorenal Vasodilators or beta blockers, and apoptosis, positive inotropesother agents to block fibrosis, Digitalis and to relieve ventricular neurohormonal remodeling, diuretic to wall stress arryhthmic activation perfuse kidneys substrates

Hemodynamic

Neurohormonal Therapies to

1940s

1960s

1970s

1990s2000

Pepper, Arch Intern Med 1999.

Definitions of Heart Failure

Proposed Definitions

Systolic Heart Failure Clinical signs and symptoms - dyspnea, edema, fatigue CXR - pulmonary congestion Typical clinical response to treatment Reduced systolic function - EF < 0.50

Diastolic Heart Failure Clinical signs and symptoms - dyspnea, edema, fatigue CXR - pulmonary congestion Typical clinical response to treatment LV EF > 0.50 Diastolic dysfunction by cath LVEDP

Circulation 2000;101:2118-2121

Device Therapy Digoxin

AntiArrhythmic

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Diuretic

ACE-I Or ARB

Beta Blocker Statin

Aldosterone Blocker

A/C

Ventricular Resynchronization
Sinus node

AV node
Conduction block

Intraventricular Activation Organized ventricular activation sequence Coordinated septal and freewall contraction Improved pumping efficiency
Stimulation therapy

Kass D. New dimensions in device-based therapy for heart failuremechanisms of stimulation for heart failure. Heart Failure Society of America 1999.

VNHI

At present, there are no data available on the trends of heart failure and other cardiovascular diseases in Vietnam

The present study attempts to address this important issue in a hospital-based survey

Aim

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Describes contemporary trends in hospitalization for heart failure in Vietnam Heart Institute (VNHI)

Study Design
Retrospective
Cross-sectional Hospital-based Survey

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Method
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Data from patient case records; 2003 2007

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

Retrospectively identified all hospitalizations occurring within VNHI where heart failure was coded.

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Sample Population Characteristic:

45176 subjects 51.3% men and 48.7% women Mean age: 51.3 18.4 years

8958 patients (19.8%) were coded with

a diagnosis of heart failure
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19.8%

Heart Failure Others

Heart failure and cardiovascular diseases at VNHI

Endocarditis DVT Pericardial disease PAD Cardiomyopathies Cerebrovascular disease Congenital heart disease Ischemic heart disease Heart failure Arrhythmia Hypertension Rheumatic heart disease
0 5 10 15 20 25 30

0.9% 1.6% 2.4% 2.4% 3.8% 4.6% 8.7% 18.3% 19.8% 20.2% 20.4% 30.8%
35

Hospitalizations for heart failure in age-groups and sex-groups %

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35 30 25 20 15 10 5 0
< 20 20-39 0.7% 0.7% 8.7% 10.6%

31.5%

Male
23.0%

Female

10.9% 11.3%

1.0% 1.7% 40-59 60-79 80

Age

Heart failure and cardiovascular diseases in age-groups

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8000 < 20 7000 6000 5000 4000 3000 2000 1000 0
HF

20-39 40-59 60-79 80

Hypertension Ischemic heart Rheumatic Congenital heart heart disease desease disease

Pericardial Arrhythmia disease

Cardiomyopathies

TRENDS OF HEART FAILURE

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Numbers of HF patients 2000 1416 1500 1000 500 0 1766 1900 1914

1962

2003

2004

2005

2006

2007

3500

Trends of absolute numbers of heart failure and CVD patients

3000

2500

2000

1900 1766 1416

1914

1962

1500

1000

500

1 2003 Heart Failure

2 2004

3 2005 Hypertension Congenital heart desease Cardiomyopathies PAD

4 2006

5 2007

Ischemic heart disease Pericardial disease Endocarditis DVT

Rheumatic heart disease Arrhythmia Cerebrovascular disease

A decline in the proportion of valvular-related disease

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40 30 20 10 0

36.7%

33.4%

31.5% 27.8% 27.0%

2003

2004

2005

2006

2007

An increase in the proportion of ischemic disease

%
25 20.8% 20 15 11.2% 10 5 0
2003 2004 2005 2006

24.0% 18.8% 13.5%

2007

Heart Failure in Children

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Arrhythmia

Congenital

Rheumatic

HF and CVD hospitalizations by months

1600 1400 1200 1000 800 600 400 200 0
Jan Fe b M ar c h Ap ril M ay Ju ne Ju ly Au gu st Se pt Oc t No v De c

Heart Failure Hypertension Ischemic heart disease Rheumatic heart disease

CHF Treatment
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Commonly Utilized Therapies Digitalis - Reduce CHF Symptoms Diuretics - Best for treating edema and pulmonary congestion Inexpensive Effective Widely available

Hints on Digitalis and Diuretics

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Digoxin No reduction in mortality Reduce CHF symptoms Withdrawl may precipitate CHF Narrow therapeutic window compared to toxicity window

Diuretics No reduction in mortality Reduce CHF symptoms May be used intermittently May paradoxically activate the RAAS

Post MI Drug Therapy

LMW Heparin

Clopidogrel

Digoxin
CP943451-2

Effect of b-Blockade on All-Cause Mortality

P=.22

CIBIS-I: 1.9 years

placebo 67/321 (20%); bisoprolol 53/320 (16%) CIBIS-II: 1.3 years

P=.0001

placebo 228/1320 (17%); bisoprolol 156/1327 (12%)

P=.006

MERIT-HF: 12 months placebo

217/2001 (11%); metoprolol 145/1990 (7%)

P=.001

US Carvedilol Trials: 7.6 months

placebo 31/398 (8%); carvedilol 22/696 (3%)
0.25 0.5 0.75 1 1.25 1.5 1.75 2

Relative risk and 95% confidence intervals

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 demonstrated carvedilol was superior to metoprolol, 6% absolute risk reduction Caution: Val-HEFT suggested use of BB with Ace and ARB might increase mortality Hypotension appeared to be the mechanism

Length of stay of in-hospital HF patients in Vietnam

Number of day
16 14 12 10 8 6 4 2 0

13.5

12.6

12.4

12.5 11.2

2003

2004

2005

2006

2007

Conclusion
Heart failure is the common cause of hospitalization in 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.

Take home message

Strategies aiming to reduce hospitalization must include the identification and management of comorbid conditions in addition to addressing HF manifestations.

Thanks for your attention!