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Cardiac Remodelling with ARNI-5.pptx
1. Cardiac Remodelling & Role of ARNi in
HF pts:
Dr. Kush Kumar Bhagat
MD, DM
Consultant Interventional Cardiologist and Electrophysiologist
EHCC HOSPITAL , Jaipur
2. Structure of presentation ---
1.The concept of Remodelling
2.Ventricular Remodelling and compensatory
mechanisms
3.Techniques for assessing ventricular remodelling
4.Patterns of Ventricular remodelling
5.Reverse remodelling
6.Myocardial recovery in clinical setting
7.Therapeutic intervention in Cardiac remodelling
8.Conclusion –cardiac remodelling
9.Role of SACUBITRIL/VALSARTAN IN REVERSE CARDIAC
REMODELLING
Cardiac Remodelling and Role of Sacubitril /
Valsartan in HF pts
3. The responses of myocardium and vasculature to
potentially noxious hemodynamic, metabolic and
inflammatory stimuli, a process which is initially
functional, compensatory and adaptive in nature but,
when sustained, progresses to structural alterations
which become self-perpetuating and pathogenic per se.
Remodeling involves intrinsic responses of the specific
cardiovascular cells – cardiomyocytes, endothelium,
smooth muscle cells - but also the interstitial cells
and matrix
Ref- Richard W. Smalling, MD, PhD Univ of Texas Medical school
1.The concept of Remodelling
4. Definition:
Alteration in ventricular architecture, with
associated increased
volume and altered chamber configuration, driven on
a
histologic level by a combination of pathologic
myocyte
hypertrophy, myocyte apoptosis, myofibroblast
proliferation,
and interstitial fibrosis.
4
Ref- Richard W. Smalling, MD, PhD Univ of Texas Medical school
2. What is Ventricular Remodeling?
5. 2. A. Ventricular Remodeling
First described by William Harvey in 1628
5
Ref- Richard W. Smalling, MD, PhD Univ of Texas Medical school
6. 1. LV Dilation after an insult such as MI, myocarditis,
toxic insults or other similar events
2. Hypertrophy of LV wall in an attempt to normalize
wall stress (law of Laplace)
3. LV may assume a more globular shape which further
impairs myocardial contractile efficiency
4. Short term: Compensatory
5. Long term: Harmful
6
Ref- Richard W. Smalling, MD, PhD Univ of Texas Medical school
2 B. Ventricular Remodeling: compensatory Mechani
7. • Echocardiography (2 D and 3
D)
• Cardiac CT Angio
• Cardiac MRI
7
Ref- Richard W. Smalling, MD, PhD Univ of Texas Medical
Echocardiography is by far the
most used and easy method for
assessment of cardiac remodeling
indices which include LVEDV;
normal <76 ml/m2, LVESV; normal
<30 ml/m2, left atrial volume
index (a value ≥34 ml/m2), LV mass
index (normal <89 g/m2 in women
and <103 g/m2 in men) and doppler
derived early diastolic filling
velocity (E wave) and early
diastolic mitral annular velocity
(e); an E/e ratio. These indices
have independent prognostic
utility for predicting clinical
outcomes in patients with LV
dilation and/or decreased LVEF.
3.Techniques for Assessing Ventricular Remodelin
8. 4. Patterns of LV remodelling with cardiac magne
resonance imaging
9. Definition:
Regression of pathological
myocardial
hypertrophy, chamber shape
distortions, and dysfunction
that may
occur spontaneously or in
response to
therapeutic interventions.
9
Ref- Richard W. Smalling, MD, PhD Univ of Texas Medical
5. Reverse Remodeling
10.
11. 11
Ref- Richard W. Smalling, MD, PhD Univ of Texas Medical school
6. Myocardial Recovery in Clinical Settings
12. 12
Pharmacological
treatment of cardiac
remodeling, which can be
divided into three
different stages of
strategies:---
Consolidated- ACEI, ARB,
BB
Promising– SACUBITRIL
Potential strategies.-
GALECTIN3,METFORMIN ,
TORSEMIDE ,
Arq Bras Cardiol. 2016; 106(1):62-69
7. Therapeutic Interventions for Cardiac remodel
With a Proven Benefit in Heart Failure
13. • Spontaneous reverse remodeling
30-50% of patients with:
1- Peripartum cardiomyopathy
2- Acute lymphocytic myocarditis
13
7. B .Reverse Remodeling in Acute/Subacute
Cardiomyopathies
15. • Spontaneous reverse remodeling
• Amelioration of toxic insults
• Revascularization if myocardium is ischemic but
viable
• PCI
• CABG
15
7 D. Reverse Remodeling in Acute/Subacute
Cardiomyopathies
16. • Spontaneous reverse remodeling
• Amelioration of toxic insults
• Revascularization
• Medical therapy for HF (BB and RAS blockade)
• Therapeutic device
16
Ref- Richard W. Smalling, MD, PhD Univ of Texas Medical school
7.E Reverse Remodeling in Acute/Subacute
Cardiomyopathies
17. 1. Cardiac remodeling refers to the structural and functional
changes of left ventricle in response to internal or
external cardiovascular damage or pathogenic risk factors;
cardiac remodeling precedes clinical heart failure.
2. Patients with elevated or increasing LV mass, LV
dilatation, or both, have unfavorable cardiovascular
outcomes.
3. Pharmacologic treatments for congestive heart failure
remain the first line therapy but in many patients they
provide limited symptom and functional improvement.
4. Mechanical interventions including LV unloading with LV
Assist devices, valve replacement/repair, surgical volume
reduction techniques as well as percutaneous volume
reduction techniques continue to evolve and hold
significant promise for the future in this challenging
group of patients.
17
8. Conclusions
18. In the PROVE-HF, reduction in N terminal pro–b-
type natriuretic peptide (NT-proBNP)
concentration was significantly correlated with
improvements in cardiac volume and function at
12 months in patients with HFrEF treated with
sacubitril/valsartan, suggesting that reverse
cardiac remodeling may be a major factor
responsible for the clinical benefit observed
with sacubitril/valsartan
9. Role of SACUBITRIL/VALSARTAN IN REVERSE
REMODELLING
19. • To the best of our knowledge, this was the first study to address the
effects of Sacubitril-Valsartan on MW parameters
• In a group of highly symptomatic chronic HF patients, Sacubitril-
Valsartan therapy was associated with GCW and GWE improvement.
• The relative increase in GCW (20.0%) and GWE (11.5%) were numerically
lower than the relative improvement in GLS (27.1%)
CONCLUSIONS
