heart failure with preserved ejection fraction · what is heart failure with preserved ejection...
TRANSCRIPT
![Page 1: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/1.jpg)
Heart Failure with Preserved Ejection Fraction
Duke Heart Failure Symposium Dennis Abraham MD
10-5-13
Disclosures: None
![Page 2: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/2.jpg)
Objectives
• Review pathophysiology as
it relates to management • Rational approach to work-
up & treatment
![Page 3: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/3.jpg)
Talk Overview
• Prevalence/Definition • Pathophysiology • Diagnosis • Treatment
![Page 4: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/4.jpg)
HFpEF is Increasingly Prevalent
Steinberg et al Circulation 2012
![Page 5: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/5.jpg)
What is Heart Failure with Preserved Ejection Fraction ?
“A rose by any other name would smell as sweet” - William Shakespeare
Heart Failure with Preserved Ejection Fraction Heart Failure with Normal Ejection Fraction
Diastolic Heart Failure Non-systolic Heart Failure
Clinical Syndrome of Heart Failure
Normal/Near Normal LV dimensions
Normal/Near Normal Ejection Fraction
Abnormalities in Relaxation
![Page 6: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/6.jpg)
HFpEF is the result of thick & non-compliant hearts? Hypertension
Diastolic Dysfunction
Adapted from Shah Nat Rev 2012
Concentric Hypertrophy
HFpEF
![Page 7: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/7.jpg)
Current Paradigm of HFpEF
Diastolic Dysfunction
Adapted from Shah Nat Rev 2012
Normal 31%
Concentric Remodeling
27%
Concentric Hypertrophy
26%
Eccentric Hypertrophy
16%
HFpEF
Hypertension
Renal Dysfunction
Obesity Deconditioning
Diabetes
Ischemia
Arterial Stiffness VV coupling
Diminished Reserve
Chronotropic Incompetence
Pulmonary Hypertension
![Page 8: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/8.jpg)
Prolongation of Diastole and Increased Ventricular Stiffness in HFpEF
Zile et al NEJM 2004
![Page 9: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/9.jpg)
Increased Contractility & Arterial Stiffness Exaggerated BP response
Kawaguchi et al Circulation 2003 Figure adapted from Borlaug EHJ 2011
Normal HFpEF
![Page 10: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/10.jpg)
Exercise Intolerance in HFpEF patients Diminished Cardiac Reserve
Borlaug et al Circulation HF 2010
![Page 11: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/11.jpg)
Diminished Heart Rate Response in HFpEF patients
Borlaug et al Circulation 2006
![Page 12: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/12.jpg)
Association between HFpEF and Pulmonary Hypertension
Lam et al JACC 2009
![Page 13: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/13.jpg)
Implications of HFpEF physiology
Pathophysiology Clinical Manifestation
1) Prolonged Relaxation & Ventricular Stiffness
- Intolerance to tachycardia or volume loading
2) Increased Contractility & Arterial Stiffness
- Large swings in BP with changes in afterload/preload
3) Diminished Systolic & Diastolic Reserve
- Exercise intolerance; absence of abnormalities at rest
4) Chronotropic Incompetence - Exercise intolerance; poor response to β-blockade
5) Pulmonary Hypertension -Augmented RHF symptoms; ventricular interdependence
![Page 14: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/14.jpg)
Echo Measures of Diastolic Dysfunction
28 y/o F no HF 40 y/o M with Diastolic HF
![Page 15: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/15.jpg)
Echo Measures of Diastolic Dysfunction
Zile & Brutsaert Circulation 2002
![Page 16: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/16.jpg)
Echo Measures of Diastolic Dysfunction
Zile & Brutsaert Circulation 2002
![Page 17: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/17.jpg)
Elevated E/e’ correlated with LV stiffness
Normal HFpEF
E E
e’ e’ E/e’(lateral) ≥ 8
Sensitivity 83%; Specificity 92% Area under ROC 0.901
Kasner Circulation 2007
![Page 18: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/18.jpg)
Diagnostic Approach for HFpEF HFpEF
Dilated LV
Valve Dz. AR; MR
No Valve Dz. High output
Non-Dilated LV
Increased Wall Thickness
Normal Wall Thickness RV Dysfxn.
<QRS Voltage Infiltrative CM
No AoV disease
No HTN HOCM; Fabry’s
HTN Hypertensive CM
AoV stenosis
>QRS Voltage
No Ischemia Restrictive; Collagen-vascular;
chemo/radiation; infiltrative, comorbid dz.; non-cardiac
Mitral Obs. MS; myxoma
No Mitral Obs.
No Pericardial Dz. Pericardial Dz.
Ischemia
PH RVMI
Adapted from HFSA 2010 Guidelines
![Page 19: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/19.jpg)
HFrEF therapies with little efficacy in HFpEF
ACEI
ARB
β-Blockers
PEP CHF EHJ 2006
IPRESERVE NEJM 2008
OPTIMIZE-HF JACC 2009
SOLVD NEJM 1991
CHARM-ALT Lancet 2003
OPTIMIZE-HF JACC 2009
HFrEF HFpEF
![Page 20: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/20.jpg)
Tailored HFpEF therapies
Exercise Intolerance
Pulmonary Hypertension
Ventricular Stiffness
Intervention Exercise Sildenafil Spiro
V02 + = = Diastolic fxn = = + Remodeling = = +
Arterial Stiffness = = ? Kitzmann et al JACC 2013
Taylor et al Int J. Card. 2012 Redfield et al JAMA 2013
Edelmann et al JAMA 2013
![Page 21: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/21.jpg)
Guidelines based treatment of HFpEF • Control Hypertension (I,A) • Slow Ventricular Rate in Atrial
fibrillation (I,C) • Treat Congestion/Edema (I,C)
• Treat/Prevent Ischemia (IIA,C) • Restore/Maintain sinus rhythm
(IIB,C) • Using β-blockers, ACEI, ARB,
CCB when HTN controlled (IIB, C) • Use of digoxin (IIB,C)
AHA/ACC Guidelines 2009
![Page 22: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/22.jpg)
Clinical Pearls for Managing HFpEF • Careful management of fluid (weight checks) • Counseling on dietary sodium intake • Starting an exercise program • Consider exercise testing when dx is unclear • Close examination of LV geometry, valvular fxn
and pericardial disease • Mindful of β-blockade in the setting of
chronotropic incompetence and RV dysfunction • Aggressive treatment of HR in atrial fibrillation
and cardiac ischemia may be beneficial • Treatment with vasodilators and spironolactone
may have advantages in loading and stiffness
![Page 23: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/23.jpg)
Summary
• HFpEF is characterized by abnormalities in relaxation, contractility, vascular stiffness, cardiovascular reserve and pulmonary pressures
• Non-invasive dx. of diastolic dysfunction- diastolic blood flow across and movement of MV
• HFpEF can be caused by numerous etiologies • Current therapies aimed at HFrEF have little role
in HFpEF • Exercise and Spironolactone may be beneficial
![Page 24: Heart Failure with Preserved Ejection Fraction · What is Heart Failure with Preserved Ejection Fraction ? “A rose by any other name would smell as sweet” - William Shakespeare](https://reader035.vdocuments.mx/reader035/viewer/2022071003/5fc07fa5dc1834718b26620a/html5/thumbnails/24.jpg)
Questions