1) Current treatments for HFpEF have not been shown to reduce morbidity or mortality, though trials are investigating new drug classes like ARNIs, soluble guanylate cyclase stimulators, and SGLT2 inhibitors. 2) Lifestyle modifications including exercise training, weight loss, and salt restriction may help symptoms. Exercise training in particular may improve exercise capacity. 3) Screening for underlying causes like myocardial ischemia, atrial fibrillation, amyloidosis, and treating associated conditions is recommended. The ATTR-ACT trial found tafamidis reduced cardiovascular hospitalizations and mortality in transthyretin amyloid cardiomyopathy.

1. HFPEF : CURRENT AND FUTURE
THERAPEUTIC PERCEPTIVE
Dr. Han Naung Tun
ESC Clinical and Research Working Groups
European Society of Cardiology
Nov, 2018

2. DISCOLSURE
There is nothing to declare

3. ESC DEFINITION OF HFPEF

4. ESC 2016 : HFPEF
ESC 2016 :
No treatment has been shown to reduce
morbidity and mortality in patinets with
HFpEF or HFmrEF

5. OUTCOMES TRIALS IN HFMREF-HFPEF
EF >45%
EF ≥40% EF ≥40%
EF ≥45%

6. ESC 2016 RECOMMENDATIONS FOR HFPEF

7. Are all risk factors optimally controlled ?
BP< 130/80 ( target 120/80 mmHg ? ( especially by RAAS-inhibitors)
HBA1c <6.5 mg%
Myocardial ischemia? Statin indicated ?
Is there inadequate RR increase during exercise ?
Stress test- Treat!
How is HR under stress?
Tachycardia- antitachycardia therapy
Chronotropic incompetence –bradycardic substance
AF?- Restore SR?
Sign of hypervolemia ? Dyspnoea on exertion ?
Start/increase loop diuretics, salt retention
Weight reduction, regular physicial activity
Current Treatment Strategies

10. TOPCAT
CV Death HF hospitalizations
Pitt et al. 2014

12. Does the patient have HFpEF?
Does the patient have rare cause of
HFpEF?
Does the patient meet TOPCAP
criteria?
TOPCAP enrollment
criteria
(must meet four criteria)
1.History of HF
Presentation or elevated
BNP
2.Baseline K level
<5mmol/l
3. Serum Cr < 2.5 mg/dl
4. eGFR >30 ml/min/1.73
m2
Continue to follow up
electrolytes and renal
function every three
months
Treat underlying cause of
HF
Pursue alternative
diagnosis
Check renal function, and
potassium at 1 week and one month
Pursue alternative
treatments
Treat with Spironolactone 25 mg
daily
No
No
Yes
Algorithm For Spironolactone in HFpEF

14. NEW TREATMENT OPTIONS ?
1 ARNI ( sacubitil/valsartan)
2 Soluble guanylate cyclase stimulation
3 SGLT2 inhibition
4 Atrial septal shunt
5 Physical exercise
6 Specific options: TTR Amyloidosis

15. Ferro CJ, et al. Circulation ,Levin ER, et al. N Engl J Med - Schrier RW, et al. Kidney Int
5; Schrier RW & Abraham WT. N Engl J Med; Stephenson SL & Kenny AJ. Biochem J.

16. ARNI IN DIASTOLIC HF?

17. TARGETING CGMP: SOLUBLE GUANYLATE
CYCLASE STIMULATOR

19. Study Type : Interventional (Clinical Trial)
Estimated Enrolment : 735 participants
Allocation: Randomized
(Actual Study Start Date) : June 15, 2018
Estimated Primary Completion Date : May 15, 2020
Estimated Study Completion Date : June 15, 2020
VITALITY-HFpEF
ClinicalTrials.gov Identifier: NCT03547583

20. NEW ORAL ANTIDIABETES DRUGS; SGLT INHIBITION

21. REDUCE LAP-HF-STUDY

22. Hasenfuss G et al., J Card Fail, 2015 Jul, 21(7):594-600

23. Hasenfuss G et al., J Card Fail, 2015 Jul, 21(7):594-600

25. Hasenfuss G et al., J Card Fail, 2015 Jul,
21(7):594-600

26. REDUCE LAP-HF STUDIE
Hasenfuß Lancet 2016

27. EXERCISE CAPACITY

28. EXERCISE CAPACITY
Exercise Training in Patients With Heart
Failure and Preserved Ejection Fraction
Meta-Analysis of Randomized Control Trials
Ambarish Pandey , Akhil Parashar , Dharam J. Kumbhani , Sunil Agarwal , Jalaj Garg ,
Dalane Kitzman , Benjamin D. Levine , Mark Drazner , and Jarett D. Berry
Originally published16 Nov 2014 Circulation: Heart Failure. 2014;8:33–40

29. Flow diagram for inclusion of studies in the
meta-analysis.

30. ,Jarett D. Berry, et al :Heart Failure. 2014;8:33–40

31. EX-DHF PILOT: EXERCISE TRAINING IN
ELDERLY HFPEF
Edelmann F et al., JACC 2011;58:1780–91

32. Tafamidis Treatment for Patients with
Transthyretin Amyloid
Cardiomyopathy
Mathew S. Maurer, M.D., Jeffrey H. Schwartz, Ph.D., Balarama Gundapaneni, M.S., Perry
M. Elliott, M.D., Giampaolo Merlini, M.D., Ph.D., Marcia Waddington-Cruz, M.D., Arnt V.
Kristen, M.D., Martha Grogan, M.D., Ronald Witteles, M.D., Thibaud Damy, M.D., Ph.D.,
Brian M. Drachman, M.D., Sanjiv J. Shah, M.D., et al., for the ATTR-ACT Study
Investigators*

33. 120 HFpEF patients included
16 patients (13.3%) with moderate-severe 99mTc-DPD cardiac
uptake
No mutations found on genetic testing
EMB in 4 patients demonstrated ATTR WT in all cases

34. Maurer MS et al., Circ Heart Fail. 2017 Jun;10(6)
ATTR-ACT Study

35. CONCLUSION
 Treat underlying etiology, ischemia , myocarditis…
 Treat cardiovascular comorbidities – Arterial hypertension,
diabetes, pulmonary hypertension- RAS inhibition?
 Treat non-cardiovascular comorbidities –CKD, Iron
deficiency, COPD, obesity
 Consider spironolactone
 Diuretic for symptoms relieve
 Screen for TTR amyloidosis

36. Thank You
Nov, 2018