IL CARDIOLOGO AMBULATORIALE E L’IMAGING INTEGRATO NELLO SCOMPENSO CARDIACO CRONICO: A CHE PUNTO SIAMO?

Luigi Tarantini Fellow ANMCO

UOC Cardiologia – Dip. Medicina Specialistica Ospedale “San Martino”ULSS n°1 - Belluno

Stages, Phenotypes and Treatment of HF

STAGE AAt high risk for HF but

without structural heart

disease or symptoms of HF

STAGE BStructural heart disease

but without signs or

symptoms of HF

THERAPY

Goals

· Control symptoms

· Improve HRQOL

· Prevent hospitalization

· Prevent mortality

Strategies

· Identification of comorbidities

Treatment

· Diuresis to relieve symptoms

of congestion

· Follow guideline driven

indications for comorbidities,

e.g., HTN, AF, CAD, DM

· Revascularization or valvular

surgery as appropriate

STAGE CStructural heart disease

with prior or current

symptoms of HF

THERAPYGoals· Control symptoms· Patient education· Prevent hospitalization· Prevent mortality

Drugs for routine use· Diuretics for fluid retention· ACEI or ARB· Beta blockers· Aldosterone antagonists

Drugs for use in selected patients· Hydralazine/isosorbide dinitrate· ACEI and ARB· Digoxin

In selected patients· CRT· ICD· Revascularization or valvular

surgery as appropriate

STAGE DRefractory HF

THERAPY

Goals

· Prevent HF symptoms

· Prevent further cardiac

remodeling

Drugs

· ACEI or ARB as

appropriate

· Beta blockers as

appropriate

In selected patients

· ICD

· Revascularization or

valvular surgery as

appropriate

e.g., Patients with:

· Known structural heart disease and

· HF signs and symptoms

HFpEF HFrEF

THERAPY

Goals

· Heart healthy lifestyle

· Prevent vascular,

coronary disease

· Prevent LV structural

abnormalities

Drugs

· ACEI or ARB in

appropriate patients for

vascular disease or DM

· Statins as appropriate

THERAPYGoals· Control symptoms· Improve HRQOL· Reduce hospital

readmissions· Establish patient’s end-

of-life goals

Options· Advanced care

measures· Heart transplant· Chronic inotropes· Temporary or permanent

MCS· Experimental surgery or

drugs· Palliative care and

hospice· ICD deactivation

Refractory symptoms of HF at rest, despite GDMT

At Risk for Heart Failure Heart Failure

e.g., Patients with:

· Marked HF symptoms at

rest

· Recurrent hospitalizations

despite GDMT

e.g., Patients with:

· Previous MI

· LV remodeling including

LVH and low EF

· Asymptomatic valvular

disease

e.g., Patients with:

· HTN

· Atherosclerotic disease

· DM

· Obesity

· Metabolic syndrome

or

Patients

· Using cardiotoxins

· With family history of

cardiomyopathy

Development of

symptoms of HFStructural heart

disease

But also…Rheumatological/Connective Tissue DisordersRenal Insufficiency

Exercise-induced

diastolic dysfunction

End point: exercise

capacity

Volume overload

End point: E/e’, NP,

hospitalizations

Pulmonary hypertension

RV failure

End point: PAP,

hospitalizations

Nebivololcarvedilol?

ACE-ARB?

DASH diet?

MRI: COR I(GUCH,RVEF,…)

ESC GL

MRICOR I

LV function

Etiology

Treatment

Fonarow G. et Al. JACC 2007

Optimize Registry: N = 41,267

Chronic heart failure: one disease with a wide but continuous spectrum of phenotypes.

Systemic Hypertension and HF Phenotype

Osservatorio CV - Trieste 2009-2013, n=2610 (28%)

Centro CardiovascolareTrieste

HFpEF borderline

22%

HFpEF52%

HFrEF26%

CAD/Valvular/SH 17%

HFpEF borderline

14%

HFpEF74%

HFrEF12%

Valvular/SH 22%

HFpEF borderline

18%

HFpEF50%

HFrEF32%

CAD/SH 29%

HFrEF11%

HFpEF77%

HFpEF b12%

SH-HF phenotype 29%

“Heart Failure with Preserved Systolic Function is a descriptiveapproach that makes no assumptions about our knowledgeabout the pathophysiology of this disorder”(Burkoff D, Maurer MS, Packer M. Circulation 2003)

Differential diagnoses for heart failureand heart failure-like syndromes in the presence of a preserved LVEF

DHF (slowed LV relaxation ±increased chamber stiffness)

•Hypertensive cardiomyopathy

•Diabetic cardiomyopathy

•Hypertrophic cardiomyopathy

•Restrictive cardiomyopathy

•Infiltrative cardiomyopathy

•Cardiac storage disease

•Arterial hypertension

•Reduced aortic distensibility

•Unsuccessful ageing

Systolic LV dysfunction or otherclinical condition and Normal EF

•Reversible myocardial ischemia

•Severe valvular stenosis or

regurgitation

•Chronotropic incompetence

•Right-sided heart failure

•Cor pulmonale

•Mitral or tricuspid valve stenosis

•Atrial myxoma

•Constrictive pericarditis

Noncardiac causes of heart failure-like symptoms and signs

•Anemia•Thyrotoxicosis•Obesity•Pulmonary parenchymal disease•Pulmonary vascular disease•Renal disease•Hepatic disease•Chronic venous insufficiency•Medication adverse effects•Deconditioning

The relevance of ventricular-arterial interaction in HFPEF

• ↑end-systolic load

• ↑ventricular wall stress

• Ventricular relaxation

• ↑Ventricle mass

• ↑left atrial volume

• ↑Δ Blood Pressure

• Diastolic Blood Flow

• ↑ myocardial ischemiaRafey M. Clev. Clin. Med. J. 2009

CardiacInsult

Cardiac muscleDysfunction

VentricularDysfunction

Dilatationremodeling

pumpfailure

congestiveHeart failure

DEATH

De Keulenaer and Brutsaert , Progr Cardiovasc. Dis 2007

The vicious circle paradigm of CHF

A

B

CD

Architettura del miocardio ventricolare

sinistro

r

Strato miocardico esternoSotto-EPICARDICOfibre longitudinali

elica oraria

Strato miocardico internosotto-ENDOCARDICO

fibre longitudinali elica anti-oraria

Strato miocardico centraleCIRCONFERENZIALE (60%)

Lower R. Tractus de corde, Oxford, Univ. Press, 1932

Progressivo Aumento del Rischio di Scompenso Cardiaco

con l’aumento della Massa VS

Gottdiener JS. JACC 2000;35:1628

1,0 1,1

1,5

1,9

2,8

0,0

0,5

1,0

1,5

2,0

2,5

3,0

Ris

chio

Rel

ativ

od

i Sco

mp

enso

Car

dia

co

Q1 Q2 Q3 Q4 Q5

Quintili di Massa Ventricolare Sinistra (ECG)

5888 soggettiEtà > 65 anni

The Cardiovascular Health Study

0

1

2

3

4

Normal geometryEccentric

Hypertrophy

Verdecchia P et al., 1995, 1996

0

10

20

30

40

0

5

10

15

20

25

30

35

Krumholz HM et al., 1995 Koren MJ et al., 1991

10-year event rate (%) Events/100 patient-year

male

8-year event rate (%)

female

Normal LV mass Increased LV mass

Normal

Relative

Wall

Thickness

125 g/m2

0.45

Concentric

remodeling

Concentric

hypertrophy

Increased

Relative

Wall

Thickness

A B C D

Progression from hypertrophy to diastolic heart failure

Mandinov L. et Al. Cardiovasc. Res. 2000

83% of patients

showed a reductionof circunferentialand/or longitudinalLV systolic function

Am J Cardiol 2012; 109: 383

Early stage left ventricular dysfunction phenotypes in type II diabetic patients without known cardiac disease :

The DYDA study

43,8%21,5%

22,0%12,7%

Normal LV FunctionN =301

Isolated diastolicLV dysfunction

N =148

Isolated systolicLV dysfunction

N =151

Diastolic + SystolicLV dysfunction

N = 87LV dysfunction

N = 386

56,2%

European J. of Cardiovasc. Prev. & Rehab. In press

The clinical relevance of the impaired systolic functionin HFPEF

Bourlag B et Al. JACC 2009

• Echocardiography• Anatomy, morphology, ventricular function, ischemia/viability,

coronary flow, perfusion, LV synchronism, valvular

stenosis/regurgitation, …

• Nuclear Cardiology• Ventricular function, ischemia/viability, LV synchronism,

adrenergic function, …

• Cardiac Magnetic Resonance• Ventricular function, anatomy, morphology, perfusion, viability,

tissue characterisation, LV synchronism, angiography, …

• Cardiac Computed Tomography• Angiography, ventricular function, perfusion, tissue

characterisation

Cardiovascular Imaging in

Multimodality Enviroment

Conclusions

• Especially in Cardiology there is a continuing development in medical technologies expanding the available measurementswith overlapping capabilities

• The selection of which test to use and when in HF patientsshould be based on a broad perspective and expertknowledge of what each available technique can offer, itssafety, feasibility, costs and impact on clinical outcome.

• Appropriate multiparametric/multimodality imaging approachmay offer effective responses in the multiple critical issues stillpresent in the diagnosis, management and risk stratificationof HF patients.

“ Bisogna avere in sé il caos per partorire una stella che danzi.” Friedrich Nietzsche

Grazie dell’attenzione !!!!