AHVC ASM 2016

1. Heart Failure in Women:
More than EF?
Dr Goh Ping Ping
Cardiologist
Asian Heart & Vascular Centre

2. Overview
• Review pathophysiology as it relates to diagnosis and
management
• Rational approach to workup: role of
echocardiography/cardiac imaging
• Therapeutic options

3. Heart Failure: A Clinical Diagnosis
Diagnostic features:
• History
• Symptoms & signs
• ECG
• CXR
• Natriuretic peptide
Differentials:
•CXR
•Renal function test, liver function
test, full blood count, thyroid
function
• Urinalysis
• Peak flow or spirometry

4. Typical Heart Failure Patient

5. Typical Heart Failure Patient: Reduced LV Systolic Function
(HFrEF)
The left ventricular ejection
fraction is IMPAIRED
Mild >35 to 50%
Moderate > 25 to 35%
Severe <= 25%

6. LVEF is an Independent Predictor of Mortality
Digitalis Investigation Group (DIG)
7788 stable HF patients
Lower EF independently a/w
increased mortality after
multivariate adjustment
Curtis et al. J Am Coll Cardiol, 2003; 42(4):736
Kaplan Meier survival curves stratified by LVEF groups

7. Characterise Heart Failure:
Reduced vs Preserved EF
One-third to half of heart failure hospitalisation due to abnormal
diastolic function
O Echo at least 2 EF 40-50%
O LA enlargement, LV wall thickness ≥ 12 mm or
O Doppler abnormalities

9. What is HFpEF?
(Heart Failure with Preserved Ejection Fraction)
Heart Failure with Preserved Ejection Fraction
• Heart Failure with Normal Ejection Fraction
• Diastolic Heart Failure
• Non-systolic Heart Failure
• Hypertensive-Metabolic Heart Failure
Clinical syndrome of HF
Normal/near normal
Ejection Fraction
Normal/near normal
LV dimensions
Abnormalities in
Relaxation

11. HFpEF: prognosis
• HFpEF: prognosis is not benign
• 30-day re-admission is initially lower than HFrEF
• Higher BP, higher creatinine
• Length of stay, 30-day mortality and 1 year mortality as
high as HFrEF
Comparison of characteristics and outcomes of patients withheart
failure preserved ejection fraction versus reduced left ventricular
ejection fraction in an urbancohort.
Boston University Medical Center
Am J Cardiol 2014 Feb 15;113(4):691-6

12. Primary Diastolic Heart Failure
Hypertension
Cardiomyopathy
- hypertrophic
- restrictive
- infiltrative
Coronary Artery Disease
Diabetes
Obesity
Sleep Apnoea
Constrictive Pericarditis

13. HFPEF: Result of thick and non-compliant heart?
Hypertension
Concentric LVH
Diastolic dysfunction
HFPEF

14. Current Paradigm of HFpEF
Diminished
reserve
Arterial stiffness
V-V uncoupling
Diastolic
Dysfunction
Pulmonary
hypertension
Chronotropic
incompetence
Shah Nat Reserve 2012
HFpEF Deconditioning
Hypertension
Ischemia
Diabetes
Obesity
Renal Dysfunction
31%
Normal
27%
Concentric
remodeling
26%
Concentric
hypertrophy
16%
Eccentric
hypertrophy

20. Accurate Assessment of Left Ventricular
Systolic Function
M-mode Biplane Simpson Spectral Tracking
automated border
detection
3D

21. Simpson Biplane “method of dïscs”
• Total LV volume is calculated from the
summation of a stack of discs
• Less dept on geometric assumptions
better endocardial border definitionwith
contrast echocardiography

22. 3-Dimensional LV Volume Measurement
Example of three-dimensional (3D) left ventricular (LV) volumes generated by post-processing of a real-time three-
dimensional echocardiography data set, acquired in a heart failure patient scheduled for cardiac resynchronization
therapy. The LV3D model is subdivided by the software in 17 wedge-shaped (apart from the apex) subvolumes and for
each volumetric segment, it is possible to derive time-volume data (lower panel) and assess the time taken to reach
the minimum systolic volume (red dots).

23. Spectral Tracking Echo
•use 2 D images
•reflection and scattering of ultrasound in myocardial
tissue to produce speckles
• track unique speckle pattern of myocardial region
• can assess rotational motion/ torsion
•alternate method to quantify LV strain and assess
systolic and diastolic function

24. Diastolic dysfunction is Measured by by Doppler
Echocardiography
Grade 1 Grade 2 Grade 3
normal abnormal pseudonormal restrictive
relaxation

25. Mitral Annular Velocity by
Tissue Doppler Imaging
E/E’ correlate with LV
filling pressure or
pulmonary capillary wedge
pressure
Normal or pseudonormal mitral inflow?
Normal filling pressure
- normal E’
Increase filling pressure -
Decrease in E’, increase in E

26. Mitral Inflow Propagation Velocity (Vp)
Normal filling
Vp ≥ 50 cm/s
Abnormal filling
with delayed flow
propagation
E/Vp ≥1.5
predicts
PCWP > 15 mmHg

27. Relation between symptomatology and diastolic function
• Grade 1 (abnormal relaxation):
– may have dyspnoea on moderate or extreme exertion; may dev CCF
symptoms if atrial contraction lost e.g.AF
• Grade 2 (increased filling pressure)
– may have symptom with mild – moderate exertion
• Grade 3 (restrictive reversible filling pattern)
– symptom at rest or mild exertion
• Grade 4 (restrictive irreversible)
– data showed increased mortality

28. Diagnostic Approach for HFpEF

30. Angiotensin Receptor Blockers in HFpEF
• Blocks Angiotensin II which promotes cardiomyocyte hypertrophy
• Blocks association of AT II with AT I receptor
• 2 large trials:
– 1. Candesartan in Heart Failure Reduction in Mortality (CHARM)-
Preserved trial : randomized 3,023 patients, NYHA function class II–IV,
LVEF= 40%. Benefit in reduction of heart failure hospitalisation vs
placebo
– 2. I-PRESERVE: 4,128 patients aged 60 years or above with HF, LVEF
at least 45%, NYHA class II–IV symptoms with an HF hospitalization 6
months prior to enrolment, or ongoing NYHA class III or IV symptoms
without hospitalization. No significant diff vs placebo.

32. Angiotensin Receptor Neprilysin Inhibitor (Valsartan/ Sacubitril)
vs Valsartan alone in HFpEF (n= 266):
Significant reduction of NT-proBNP from baseline to week 12
Improvement in LA remodeling and NYHA class at 36 weeks

33. PARAGON-HF
• Use of Entresto (valsartan/sacubitril) in HFpEF
• Study of 4300 pts
• Results in 2019

34. The Role of Statin?
Prospective study of HFpEF patients (EF> 50%):
– matched population of 2,074 statin users
and 2,074 non-statin users
– Use of statin associated with improved
outcome: higher rate of 1-year survival
(85.1% vs 80.9%, HR 0.80; 95% CI 0.72–
0.98, P = 0.01).
– reduced CV death (HF 0.86; 95% CI
0.75–0.98; P = 0.026) and reduced
composite all-cause mortality (HR 0.89;
95% CI 0.82–0.96; P = 0.003)
Alehagen et al. Circ Heart Fail. 2015;8(5):862–870)

35. Role of Statin
ACCF/AHA HF guidelines support use of statin therapy for
patients with known atherosclerotic disease, but statins are
not currently recommended for the treatment of HF alone in
the absence of other indications

36. 2013ACCF/AHA Guideline for Management of Heart Failure

37. Management of HFpEF
• Careful fluid management (weight checks)
• Restrict sodium intake
• Close examination of LV geometry, valvular function and pericardial
disease
• Consider exercise test when diagnosis is unclear
• Aggressive control of heart rate in AF and treatment of ischemia
• Be mindful of betablockade in presence of chronotopic incompetence
and RV dysfunction
• Vasodilators and Spironolactone may have advantages in loading and
stiffness

38. Consider Entity of HFpEF
Older
Women
Hypertension
Obesity
Atrial Fibrillation

39. Thank You