Heart failure with preserved ejection fraction

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Presentation about heart failure with preserved ejection fraction. Current epidemiology, pathophysiology, diagnostic approac and evidence-based treatment are presented.

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Heart failure with preserved ejection fraction

  1. 1. Evidence Based Management of Heart Failure with Normal/Preserved Ejection Fraction Moises Auron, MD FAAP FACPMoises Auron, MD FAAP FACP Hospital MedicineHospital Medicine October 2009October 2009
  2. 2. Diagnostic Criteria • Symptoms and signs compatible with heart failure • Left ventricular ejection fraction >50% • Exclusion of severe valvular disease and pericardial disease Hunt SA et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. Circulation 112: e154–e235
  3. 3. Epidemiology • 20% to 60% of patients with HF • Increasing prevalence Hunt, et al. 2009 ACCF/AHA Heart Failure Guidelines. (Circulation. 2009;119:e391-e479. Owan T, et al. NEJM. 2006;355:251-9
  4. 4. Pathophysiology • Reduced ventricular compliance (myocardial stiffness) and fluid retention • Abnormal renal sodium handling and arterial stiffness, in addition to myocardial stiffness • The majority of patients have a history of hypertension • Most of the patients have evidence of LVH on echocardiography. • More frequent in elderly women Hunt, et al. 2009 ACCF/AHA Heart Failure Guidelines. (Circulation. 2009;119:e391-e479.
  5. 5. Pathophysiology Aurigemma GP. NEJM. 2004;351:1097-105.
  6. 6. Pathophysiology Cliger C, et al. AJGC. 2006;15:50–57
  7. 7. Aurigemma GP, et al. Circulation 2006; 113: 296–304 Systolic HF Normal heart Diastolic HF Pathophysiology
  8. 8. Single syndrome hypothesis Ouzounian M. Nature Clin Pract Cardiovasc Med. 2008; 5(7): 375-86
  9. 9. Aging and HF with preserved EF • Decrease in the elastic properties of the heart and great vessels • Subsequent increase in SBP an increase in myocardial stiffness. • Decrease in ventricular filling due to: – structural changes in the heart (fibrosis) – decline in relaxation and compliance. – decrease in beta-adrenergic receptor density – decline in peripheral vasodilator capacity • Elderly patients associated disorders – CAD – DM – aortic stenosis – Atrial fibrillation – Obesity), – Sex-specific  women are more susceptible. Hunt, et al. 2009 ACCF/AHA Heart Failure Guidelines. (Circulation. 2009;119:e391-e479.
  10. 10. Ouzounian M. Nature Clin Pract Cardiovasc Med. 2008; 5(7): 375-86
  11. 11. Myocardial disorders associated with HF and normal LVEF • Restrictive cardiomyopathy • Obstructive hypertrophic cardiomyopathy • Nonobstructive hypertrophic cardiomyopathy • Infiltrative cardiomyopathies Hunt, et al. 2009 ACCF/AHA Heart Failure Guidelines. (Circulation. 2009;119:e391-e479.
  12. 12. Hunt, et al. 2009 ACCF/AHA Heart Failure Guidelines. (Circulation. 2009;119:e391-e479.
  13. 13. Diastolic CHF? Understanding nondiastolic mechanisms of Heart Failure with Normal Ejection Fraction may provide further answers and, more importantly, lead to more therapeutic advances. Myocardial systolic Ventricular Vascular Renal Neurohumoral Non-CV Normal EF Heart Failure Bench T, et al. Current Heart Failure Reports 2009, 6:57–64
  14. 14. Non-diastolic mechanisms • Volume overload • Venoconstriction/volume redistribution • Ventricular vascular coupling abnormalities • Chronotropic incompetence • Endothelial dysfunction Bench T, et al. Current Heart Failure Reports 2009, 6:57–64
  15. 15. Volume overload Maurer MS. J. Am. Coll. Cardiol. 2007;49;972-981
  16. 16. Hypertension and heart failure in the setting of normal EF Cliger C, et al. AJGC. 2006;15:50–57
  17. 17. Prolonged QRS and mortality Hummel SL, et al. J Cardiac Fail 2009;15:553-60. N=872
  18. 18. Prolonged QRS and mortality Hummel SL, et al. J Cardiac Fail 2009;15:553-60. N=872
  19. 19. Diagnosis • Slow rate of ventricular relaxation is slowed • Elevated LV filling pressure in a patient with normal LV volumes and contractility. • Clinical diagnosis based on the finding of typical symptoms and signs of HF in a patient who is shown to have a normal LVEF and no valvular abnormalities (aortic stenosis or mitral regurgitation, for example) on echocardiography. • Doppler echocardiography (TTE) • BNP levels in addition to TTE improve diagnostic accuracy. Hunt, et al. 2009 ACCF/AHA Heart Failure Guidelines. (Circulation. 2009;119:e391-e479.
  20. 20. Echocardiography Aurigemma GP. NEJM. 2004;351:1097-105. E = early filling A = atrial contraction
  21. 21. Echocardiography Bursi F, et al. JAMA 2006;296:2209-2216.
  22. 22. Echocardiography Sm = peak systolic velocity septal side of the mitral valve annulus or base. Em = peak early diastolic velocity Am = peak atrial contraction velocity Sanderson JE. Prog Cardiov Dis. 2006;49(3): 196-206
  23. 23. Systolic dysfunction with normal EF • New doppler echocardiography techniques reveals abnormal ventricular function particularly in the long axis. • Ejection is relatively preserved because of increased radial function. Sanderson JE. Prog Cardiov Dis. 2006;49(3): 196-206
  24. 24. Myocardial strain and torsion: Speckle-tracking echocardiography Circumferential strain from the apical LV level in a healthy individual. Homogenous circumferential distribution of normal systolic strain. Circumferential strain at the LV apical level in a patient with a LAD-related MI. Reduced systolic shortening (strain) in the anterior, septal, and inferior segments, with marked postsystolic contraction (white arrows). Early septal systolic stretching indicating dyskinesis (red arrow). Normal contraction is seen in the lateral segments. Edvardsen T. Prog Cardiov Dis. 2006;49(3): 207-14.
  25. 25. Doppler tissue imaging – validated with MRI “The present study has shown that DTI can quantify LV torsional deformation over time. This novel method may facilitate noninvasive quantification of LV torsion in clinical and research settings.” Notomi Y. Circulation. 2005;111:1141-1147.)
  26. 26. Cardiac MRI vs. Echocardiography Rademakers FE. Prog Cardiov Dis. 2006;49(3): 215-27.
  27. 27. Prognosis HR 1.13; 95%CI 0.94-1.36; P=0.18 Owan TE. NEJM. 2006;355:251-9. Bhatia RS. NEJM. 2006;355:260-9.
  28. 28. Prognosis Somaratne JB. Eur J Heart Fail. 2009;11:855-62
  29. 29. Treatment • Limited evidence. • Use of same drugs as for systolic CHF justified due to co-morbid conditions – Atrial fibrillation, hypertension, diabetes mellitus, and coronary artery disease • The management of these patients is based on the control of physiological factors (blood pressure, heart rate, blood volume, and myocardial ischemia) Hunt, et al. 2009 ACCF/AHA Heart Failure Guidelines. (Circulation. 2009;119:e391-e479.
  30. 30. Completed trials for HF with preserved EF Lam CSP. Ann Acad Med. 2009;38(8): 663-666.
  31. 31. Hong Kong trial • ACE vs. ARB vs. diuretics Yip GWK, et al. Heart 2008;94;573-580.
  32. 32. VALIDD Trial: supporting antihypertensive Tx Valsartan In Diastolic Dysfunction Lowering blood pressure improves diastolic function irrespective of the type of antihypertensive agent used. Solomon SD. Lancet 2007; 369: 2079–87
  33. 33. OPTIMIZE – HF: Betablockers Hernandez, et al. JACC. 2009 Jan 13;53(2):184-92 Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure
  34. 34. OPTIMIZE – HF: Betablockers Hernandez, et al. JACC. 2009 Jan 13;53(2):184-92
  35. 35. SENIORS: Nevibolol Study of the Effects of Nebivolol Intervention on Outcomes and Hospitalisation in Seniors with Heart Failure) Ghio S, et al. Eur Heart J. 2006;27: 562–568
  36. 36. SWEDIC: Carvedilol Bergstrom A. Eur J Heart Fail. 2004;6:453-61. Swedish Doppler-echocardiographic study
  37. 37. Statins in diastolic HF Fukuta H. Circulation. 2005;112:357-363 RR death [95% CI] 0.20 [0.06 to 0.62]; P=0.005
  38. 38. Ongoing trials • Trial of Aldosterone Antagonist Therapy in Adults With Preserved Ejection Fraction Congestive Heart Failure (TOPCAT) • Start Date: August 2006 • Estimated Completion Date: July 2013 • Spironolactone vs. placebo • N = 4500 ClinicalTrials.gov: NCT00094302
  39. 39. Hunt, et al. 2009 ACCF/AHA Heart Failure Guidelines. (Circulation. 2009;119:e391-e479.

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