Scompenso Cardiaco con frazione di eiezione preservata

Dott.ssa C.RaineriDivisione di Cardiologia, Fondazione IRCCS Policlinico S.Matteo, Pavia

ESC GUIDELINES European Heart Journal (2016) 37, 2129–2200

Definition of HFpEF

Dhingra et al. Curr Heart Fail Rep 2014 11:354–365

Proportion of heart failure patients with preserved ejection fraction based on HF registries

Prevalence of patients with HFpEF

28,820 participants from 3 community-based cohorts: 982 developed incident HFpEF during a median follow-up of 12 years.

Ho et al. Circ Heart Fail. 2016;9:e003116

Incidence of HFpEF

The American Journal of Medicine 2016; 129: 635.e15-635.e26

5,046,879 hospitalizations with a diagnosis of acute heart failure in 2003-2012

Characteristics of Patients Hospitalized with HFpEF vs HFrEF

The American Journal of Medicine 2016; 129: 635.e15-635.e26

Non cardiac co-morbidities in Patients Hospitalized with HFpEF

The American Journal of Medicine 2016; 129: 635.e15-635.e26

Cardiovascular disease in pts with HFpEF vs HFrEF

Rajalakshmi Santhanakrishnan et al. Circulation. 2016;133:484-492

Atrial Fibrillation Begets Heart Failure and Vice Versa

Framingham Heart Study participants with new-onset AF or HF between 1980 and 2012.

Hwang et al. J Am Coll Cardiol 2014;63:2817–27

Impact of CAD on Survival in Patients With HFpEF

Redfield. N Engl J Med 2016;375:1868-77

Pathophysiological Model of HFpEF

Obokata et al. J Am Coll Cardiol 2019

Pathophysiologic contributors to HFpEF

Reddy et Borlaug Current Problems in Cardiology 2016; 4: 2016, 145–188

The end diastolic pressure volume relationship in pts with HFpEF

left and upward shift of EDPVR → ↑ Diastolic LV filling press

Borlaug et al Circ J 2014; 78: 20–32

HFpEF: ↑ PCWP/LVEDP and PAP with exercise

sc-eFS : Stress-corrected endocardial fractional shorteningsc-mFS :Stress-corrected midwall fractional shortening

Borlaug et al. J Am Coll Cardiol. 2009; 54(5): 410–418

Systolic dysfunction in HFpEF

Load-Independent Measures Contractility

Chronotropic incompetence in HFpEF

Borlaug et al Circ J 2014; 78: 20–32

Myocardial Reserve Dysfunction in HFpEF

Circ Heart Fail. 2019;12:e006240

Kawaguchi et al. Circulation. 2003;107:714-720

A-V couplingin HFpEF

Arterial elastance (Ea) and Ees are elevated in tandem in HFpEF

A-V coupling

Combined ventricular-arterial stiffening leads to greater blood pressure lability, by creating a ‘high gain’ system—with amplified blood pressure changes for any alteration in preload or afterload

• Prevalence varies (36-83%) depending on the population studied, the methods(echocardiography or RHC) and the hemodynamic criteria used to diagnosePH.

• Frequently associated with RV dysfunction and uncoupling with the pulmonary circulation.

Pulmonary Hypertension in HFpEF

Guazzi Heart Failure Clin 2018; 14: 297–309

Pulmonary Hypertension and Outcomes in HFpEF

JAMA Cardiol. 2018;3(4):298-306

Elevated PVR Are Associated With Increased Mortalityin the PH-HFpEF Cohort

JAMA Cardiol. 2018;3(4):298-306

RV dysfunction in HFpEF

Melenovsky et al. Eur Heart J 2014;35: 3452–3462

The American Journal of Medicine (2016) 129, 635.e15-635.e26

• In-hospital mortality in HFpEF ranges from 2.4% to 4.9%in observational studies, with slightly higher 30-day (5%) and 60–90 day (9.5%) mortality.

• 5 years mortality ranging from 53% to 74%.

• Annualized mortality : - 10-25% in observational studies- 4-5% in large HFpEF trials

Clinical Outcome of patients with HFpEF

The survival of patients with HFpEF vs HFrEFMeta-analysis Global Group in Chronic Heart Failure

(MAGGIC)

European Heart Journal 2012; 33: 1750–1757

The primary outcome of death from any cause occurred in 2422 (23.4%) patientswith HF-PEF and in 8332 (26.3%) in those with HF-REF.

J Am Coll Cardiol. 2017;70(20):2476–86.

39,982 patients from 254 hospitals who were admitted for HF between 2005 and 2009

Outcomes of Heart Failure

Age-Related Outcomes of Patients With HFpEF

J Am Coll Cardiol 2019;74:601–12

pts with LVEF > 45% from 3 large HFpEF trials (TOPCAT, I-PRESERVE and CHARM Preserved )

Causes of Death Across Age Strata

J Am Coll Cardiol 2019;74:601–12

Eur Heart J 2019; 40, 3297–3317

Eur Heart J 2019; 40, 3297–3317

Diagnostic Workup and Scoring System

Eur Heart J 2019; 40, 3297–3317

Advanced work-up: Echo stress test

Eur Heart J 2019; 40, 3297–3317

Advanced work-up:invasive haemodynamic Measurments

Eur Heart J 2019; 40, 3297–3317

Aetiological work-up

Chamsi-Pasha JACC Cardiovasc Imaging 2019

CMR in the Evaluation of Diastolic Dysfunction and Phenotyping of HFpEF

CMR and HFpEF

Treatment of HFpEF

TOPCAT

Outcome trials in HFpEF

Clealand et al. Heart Fail Clinics 2014;10:511-523

Angiotensin–Neprilysin Inhibition in HFpEFParagon-HF trial

N Engl J Med 2019;381:1609-20

Curr Treat Options Cardio Med 2019; 21: 20

In the absence of convincingtrial data, what should we do?

Adamson et al. Circ Heart Fail. 2014;7:935-944

Primary hypothesis: hemodynamically guided HF management decreasesdecompensation leading to hospitalization.

Of the 550 patients enrolled in the study, 119 had left ventricular EF ≥40%

CHAMPION trial

Exercise Training in HFpEF

Edelmann, et al. JACC 2011; 58: 1780-9

64 patients with HFpEF mean age 65 ± 7 years, 56% female.

Randomized (2:1) to supervisedendurance/resistance training in addition to usual care vs usual care

Schwartzenberg, et al. J Am Coll Cardiol 2012;59:442–51

Need to be careful with vasodilators...