心衰竭治療的需求與重要性回顧 (REVIEW OF UNMET NEEDS IN THE TREATMENT OF HEART FAILURE)

1. 心衰竭治療的需求與重要性回顧(REVIEW OF UNMET NEEDS IN THE TREATMENT OF HEART FAILURE) 2016 內科醫學會年會 心衰竭治療的最新進展 On behalf of the Study Group of the Registry of Heart Failure with Reduced Ejection Fraction, Taiwan Society of Cardiology 殷偉賢 振興醫院 心臟內科

2. Thepresent guideline represents the commitment of the TaiwanSociety of Cardiologyto recognize heart failure as amajor health care challenge and to provide advices andresources for clinicians and related health care providers. Lack of Taiwanese data! • With guideline recommendations, we hope thatthe management of heart failure can be improved. • Current recommendations from theguidelines on the diagnosis and treatment of chronicheart failure closely resemble those contained in guidelines in the western world.

3. 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

4. Incidence of HF hospitalization, 2005 Incidence: 271.2/100,000 9.7% 81.1% Tseng et al. JAGS 2010;58

5. 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

6. Heart failure in Taiwan: outcomes Chronic decline Cardiacfunction Hospitalizations Disease progression Wang et al. Acta Cardiol Sin 2012;28:161–95

7. Taiwan Society of Cardiology Registry on Heart Failure with Reduced Ejection Fraction • Study population: • Patients with systolic HF (LVEF≦40%) and admitted for acuteHF, 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.

8. 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

9. Characteristics at Admission

10. I I IIa IIa IIb IIb III III Precipitating Causes of Decompensated HF ACS precipitating acute HF decompensation should be 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. Common precipitating factors for acute HF should be considered during initial evaluation, as recognition of these conditions is critical to guide appropriate therapy. 診斷心衰病因 找尋誘發因素 急性冠心病應及早診治 急性心衰常見誘因應及早發現處理

11. Primary Etiology of HF 44.1% Ischemic 7.9% Valvular 32.9% Dilated 7.1% Hypertensive

12. Possible Precipitating Factors

13. Signs of hypoperfusion

14. Clinical presentations Hypotension 9.9% Engorged jugular vein 23.9% Confusion/Somnolence 5.1% Pulmonary rales 63.5% S3 Gallop 18.2% Pleural effusion 28.8% Peripheral hypoperfusion 14.1% Peripheral edema 49.3%

15. wet and warm Dry and cold WET & COLD

16. Specific Management during admission 40.9%

18. Intravenous drugs and interventional procedures

19. Median Length of Stay 8 days (IQR 5~15) TSOC-HFrEF

20. In-Hospital Mortality * In-Hospital Mortality (%) 2.4% AHEAD EFICA EHFS II ATTEND RO-AHFS ADHERE GWTG-HF ALARM-HF ADHERE-AP OPTIMIZE-HF ESC-HF Pilot TSOC-HFrEF IN-HF Outcome

21. GDMT at discharge 61.6% 59.7% 49.0%

22. Why NOT using RAAS inhibitors?

23. Why NOT using beta-blocker?

24. Why NOT using aldosterone blockers? Contra-indicated Not-indicated

25. Taiwan Systolic Heart Failure Registry: follow-upat 1 year

26. 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)

28. Trends in oral medication over time

29. GDMT: Prescription & Outcomes 64.4% 35.6% 20.6% 10.7% All 3 GDMTs 18.8% 7.4% 0 GDMTs 12.3% 11.6% 8.7% 10.0%

30. Multivariate analysis for all-cause morality

31. 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 Na ≤ 135 mEq/L NYHA Fc III/IV at discharge Hypothyroidism GDMT ≤ 1 type 25.2% 41.2%

32. 2016 European HF guidelines

33. Novel oral anti-HF medications Ivabradine: specific and selective inhibitor of the If ion Channel

35. Novel oral anti-HF medications Angiotensin Receptor Neprilysin Inhibitor (ARNI)

37. New pharmaceutical targets in HF

38. Patient inertia Inotropes, vasodilators ACEi/ARB, β-blockers, MRA, Neprilysin inhibitor CRT, CCM, MV repair Diuretics

39. Patient inertia Inotropes, vasodilators ACEi/ARB, β-blockers, MRA, Neprilysin inhibitor CRT, CCM, MV repair Diuretics

40. Physician inertia

41. 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

42. Post-acute care

43. 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

44. Thank You and Have a Nice Day!