Heart Failure with Preserved and Reduced Ejection Fraction ...
Heart Failure with Preserved EF
Transcript of Heart Failure with Preserved EF
Heart Failure with Preserved EF
Dino Recchia, MD, FACC, FHFSA
Diastolic HF 2004 “Diastolic HF” c.2004
Aurigemma G, et al. NEJM 2004
1/3 - 2/3 HFpEF pts do NOT have LVH
1/3 pts in HFpEF trials had normal diastolic function
HFpEF 2018 Biological Phenotypes
HFpEF Prevalence Increasing
44% 31%
15%
13%
41% 56%
1985-1994 2005-2014
EF<40% EF 40-50% EF>50%
Adapted from Ramachandran et al JACC:Cardiovasc Imaging 2017
Chun et al Circ Heart Fail 2012
N = 8543
HFpEF is not Benign
Walter et al Eur Heart J 2014
HFpEF: A Multisystem Disease
Cardiovascular Reserve is Impaired in HFpEF
Impaired Chronotropic
Response
Impaired Peripheral
Vasodilation
Impaired Stroke Volume
Reserve
Borlaug et al Circ Heart Fail 2010
Therapeutic Failures in HFpEF
Class 1 recommendations for HFrEF = 7
Class 1 recommendations for HFpEF = 0
Spironolactone in HFpEF TOPCAT Trial
• International study
• N=3,445
• Symptomatic HFpEF
• EF >45%
• Spironolactone vs placebo
• Endpoint CV death or HF hospitalization
Pitt et al NEJM 2014
Spironolactone in HFpEF
Pfeffer et al Circ 2015
Regional Variation in Outcomes
Regional Variation in Drug Metabolite
Treatment X Benefits A >>> B > C
C
B A
Treatment X has no
overall benefit
Why have HFpEF Treatments Failed?
Guazzi M Circ Heart Fail 2014
Cluster Analysis
Shah et al Circulation 2015
HFpEF Phenotype & Prognosis
Categories of HFpEF
• “Garden-variety” HFpEF (HTN, DM, obesity, CKD)
• CAD-HFpEF
• Right heart failure-HFpEF
• A-fib predominant HFpEF
• HCM-like HFpEF
• High-output HFpEF
• Valvular HFpEF (multiple moderate lesions)
• Rare causes of HFpEF
Hwang et al J Am Coll Cardiol 2014
HFpEF & CAD
• Pts who were discharged with HFpEF and had both an echo and cath within 1 year
• Excluded pts with low EF, ACS, valve disease, HCM, and restrictive CM
• 376 pts eligible
• Results of stress testing, echo, cath reviewed
• Follow up to 10 years
HFpEF an Stress Testing
• 2/3 had CAD • 1/3 of CAD pts had 3V CAD
Hwang et al J Am Coll Cardiol 2014
Hwang et al J Am Coll Cardiol 2014
HFpEF & CAD
Obesity and HFpEF
Ndumele et al J Am Heart Assoc 2016
Risk adjusted for HTN, DM, HLP,
tobacco, physical inactivity
HFpEF Obesity Phenotype
Kitzman et al J Am Coll Cardiol 2016
Diet & Exercise Work Diet and exercise work!
Kitzman D, et al. JAMA 2016
AT = aerobic exercise training, CR = caloric restriction
New Concepts in HFpEF
• Role of the systemic vasculature
• Importance of pulmonary HTN
• “Interventional” therapies for HFpEF
• New options for cardiac amyloidosis
Pulse Wave Velocity & Premature Wave Reflections
• PWV is a measure of aortic stiffness
• Systolic wave reflections occur and are related to PWV
• Ideal PWV ‒ All wave reflections occur during
diastole when aortic valve is closed ‒ Augments coronary perfusion ‒ No change in afterload on the heart
• Increased PWV
‒ Premature wave reflections occur in late systole leading to increased afterload on the heart
Wave Reflections & Exercise Intolerance
Pulmonary HTN & HFpEF
Interatrial Shunt Device for HFpEF
Improving LV Compliance in HFpEF
Hemodynamics of Pericardiotomy
HFSA 22nd Annual Scientific Meeting
Cardiac Amyloidosis: Often Misdiagnosed and Undertreated
Page 2 of 39
HFSA 22nd Annual Scientific Meeting
Cardiac Amyloidosis: Often Misdiagnosed and Undertreated
Page 2 of 39
HFSA 22nd Annual Scientific Meeting
Cardiac Amyloidosis: Often Misdiagnosed and Undertreated
Page 2 of 39
Restrictive Cardiomyopathy
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Cardiac Amyloid – wtTTR Variant
• Most common in white males
• Seen at autopsy in 25% HFpEF pts over 85
• Found in 13% of hospitalized pts with HFpEF >60
• 12% pts undergoing TAVR for AS with low gradient
• Bilateral carpal tunnel syndrome and spinal stenosis seen in 50% cases
Cardiac Amyloid – mTTR Variant
• >100 mutations leading to various familial type amyloid syndromes: ‒ Familial amyloid polyneuropathy ‒ Familial amyloid cardiomyopathy
• Val122I mutation most common in US seen in African
Americans with 3-4% heterozygote carriers
• Restrictive CM with minimal neuropathy often misdiagnoses as hypertensive heart disease
Sensitivity 85-90%
Specificity 85-90%
Sensitivity 97% for TTR
Specificity 99% for TTR
Sensitivity 99% Sensitivity 30%
Specificity 75%
Management of Amyloid CM
• Difficult due to narrow window between too high and too low filling pressures
• Torsemide preferred diuretic
• No verapamil or diltiazem
• Avoid digoxin
• Maintain NSR
• New treatment options
New Treatment Option for TT Amyloid CM Tafamadis
• 30% reduction in all cause mortality
• 32% reduction in hospitalizations
• 12-18 months rx re needed before observing the benefit
• Significant improvement in quality of life scores
• Early detection is key
Maurer et al NEJM 2018
Thank You