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Transcript of Hfnef
Dr.DurgaPavan
HFnEF-CONCEPTS AND MANAGEMENT
Heart failure (HF) can be defined as the inability of the heart to provide sufficient forward output to meet the perfusion and oxygenation requirements of the tissues while maintaining normal filling pressures. There are two major mechanisms by which this can occur:
Systolic dysfunction, in which there is impaired cardiac contractile function.
Diastolic dysfunction, in which there is abnormal cardiac relaxation, stiffness or filling
HFnEF-CONCEPTS AND MANAGEMENT
Nearly half of patients with symptoms of heart failure are found to have a normal left ventricular (LV) ejection fraction.
This has variously been labelled as diastolic heart failure, heart failure with preserved LV function or heart failure with a normal ejection fraction (HFNEF).
The preferred term should be HFNEF because accumulative evidence suggests that the physiological abnormalities in these patients are not restricted to diastole only, and systolic function is not entirely ‘‘preserved’’ when measures other than the ejection fraction are used.
HFnEF-CONCEPTS AND MANAGEMENT
History Late seventies, the first studies appeared that
showed diastolic LV dysfunction to importantly contribute to HF in hypertrophic cardiomyopathy, aortic stenosis, and hypertensive heart disease.
First reports on HFPEF date back almost 30 years.
Pulmonary congestion was reported in a small group of elderly, mostly female African-American hypertensive patients with supranormal systolic pump function and evidence for diastolic dysfunction.
HFnEF-CONCEPTS AND MANAGEMENT
It is now well established that among patients with the clinical syndrome of heart failure (HF), approximately half have preserved systolic function, known most commonly as heart failure with preserved ejection fraction (HFpEF).
Although originally considered to be predominantly a syndrome that pathophysiologically involves abnormalities in diastolic function (relaxation and/or stiffness), ongoing investigation suggests that, although diastolic abnormalities may be present in many patients, other aspects of pathophysiology likely also contribute to symptoms
HFnEF-CONCEPTS AND MANAGEMENT
DefCurrent European Society of Cardiology
(ESC)/Heart Failure Association (HFA) recommendations requireSigns and/or symptoms of heart failure, An ejection fraction above 50% Either direct evidence of diastolic dysfunction
or indirect evidence
HFnEF-CONCEPTS AND MANAGEMENT
DebatesDHF vs HFPEF vs HFNEF (Terminology )One disease continuum vs. two distinct
disease entities
HFnEF-CONCEPTS AND MANAGEMENT
Diastolic LV dysfunction was not unique to diastolic HF but also was present in HF with systolic LV dysfunction, the term diastolic HF was largely abandoned and was replaced by the terms HF with preserved LVEF or HFNEF.
Preserved LVEF implies knowledge of a pre-existing LVEF, which is usually absent, and the exact range of a normal LVEF is hard to define.
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
PathophysiologyDiastolic LV dysfunctionSystolic LV dysfunction Impaired ventricular vascular couplingAbnormal exercise-induced and flow
mediated vasodilation,Chronotropic incompetence,Pulmonary arterial hypertension
HFnEF-CONCEPTS AND MANAGEMENT
Diastolic LV dysfunction
HFnEF-CONCEPTS AND MANAGEMENT
Diastolic MechanismsEarly rapid filling - 70% to 80% of LV filling
driven by the LA to LV pressure gradient Myocardial relaxation, LV diastolic stiffness, LV elastic recoil, LV contractile state, LA pressures, Pericardial constraint, LA stiffness, Pulmonary vein properties, Mitral orifice area
HFnEF-CONCEPTS AND MANAGEMENT
Diastasis LA and LV pressures are usually almost equal. It contributes < 5% of the LV filling, Its duration shortens with tachycardia
HFnEF-CONCEPTS AND MANAGEMENT
Atrial systole - 15% to 25% of LV diastolic fillingwithout raising the mean LA pressure. depends on
PR interval, Atrial inotropic state, Atrial preload, Atrial afterload, Autonomic tone, Heart rate.
HFnEF-CONCEPTS AND MANAGEMENT
Although diastolic function is complex, the most important components are LV relaxation and LV diastolic stiffness.
HFnEF-CONCEPTS AND MANAGEMENT
Left Ventricular Relaxation Active, energy-dependent process Begins during the ejection phase of systole , continues through isovolumic relaxation and
the rapid filling phase
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
Left Ventricular Relaxation and stiffnessDiastolic dysfunction is caused by one or
more of the following structural abnormalities:
HypertrophyFibrosisInfiltrative diseasesPericardial constrictionMyocardial edema
HFnEF-CONCEPTS AND MANAGEMENT
Left Ventricular Relaxation and stiffnessFunctional cellular abnormalities which is reversible and transient .
Causes of impaired myocyte relaxation include:Ischemia and/or hypoxiaCellular calcium overload and/or ATP
depletionCertain cardiovascular drugs, eg, digitalisThe hypertrophy process itself which alters
the contractile and metabolic phenotype
HFnEF-CONCEPTS AND MANAGEMENT
Cellular mechanisms of LV relaxation and stiffnessRole of calcium
For complete myocyte relaxation to occur, the cytosol must be largely cleared of calcium so that calcium dissociates from troponin C, and all tension-generating actin-myosin bonds must be lysed.
Increased intracellular calcium can directly impair diastolic relaxation by persistent activation of the actin-myosin cross-bridge interaction if calcium is not adequately cleared from the cytosol.
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
Role of titin Giant elastic protein expressed in cardiomyocytes
in two main isoforms, N2B (stiffer spring) and N2BA (more compliant spring).
Titin functions as a bidirectional spring responsible for early diastolic LV recoil and late diastolic resistance to stretch.
Titin is compressed when the myocyte shortens during systole.
At the beginning of cell relaxation, when the actin-myosin crossbridges detach and active shortening tension begins to dissipate, the compressed titin forcefully expands and generates an intracellular "restoring force" that relengthens the sarcomere and myocyte
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Isoform expression of titin differs in patients with SHF and DHF: in patients with SHF, titin isoform expression shifts towards the more compliant isoform, whereas in patients with DHF the shift is towards the less compliant isoform.
Isoform shifting may have an impact on diastolic function. shift to a larger isoform would predict a substantial decrease in passive myocardial stiffness.
HFnEF-CONCEPTS AND MANAGEMENT
N2BA:N2B - HFREF
N2BA:N2B - HFNEF
HFnEF-CONCEPTS AND MANAGEMENT
Systolic dysfunctionEjection fraction is an index of global
haemodynamic pump performance, insensitive to disturbances of ventricular muscle function.
A preserved ejection fraction often merely indicates that the radial (or circumferential) fibres of the ventricle have compensated for dysfunction of the longitudinal fibres.
Impaired longitudinal fibre function may be the single or most marked sign of cardiac dysfunction in HFpEF.
HFnEF-CONCEPTS AND MANAGEMENT
Patients with HFNEF have concentric LV remodeling with high LV mass/volume ratio in contrast to patients with HFREF, who have eccentric LV remodeling with low LV mass/volume ratio.
Signal transduction cascades driving myocardial remodeling differ in HFNEF and HFREF
HFnEF-CONCEPTS AND MANAGEMENT
ventriculo-vascular couplingVentricular and vascular stiffening increase with
ageing, hypertension, and diabetes, and are abnormally elevated in patients with HFpEF
Combined ventricular-arterial stiffening leads to greater blood pressure lability, by creating a ‘high gain’ system—with amplified blood pressure changes for any alteration in preload or afterload
Patients with HFpEF display attenuated exercise-mediated reductions in mean vascular resistance and arterial elastance, coupled with abnormalities in endothelial function and dynamic ventricular –arterial coupling
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
Chronotropic incompetenceChronotropic response during submaximal
and peak workload is impaired in HFpEF.
Autonomic dysfunctionBaroreflex sensitivity is reduced
HFnEF-CONCEPTS AND MANAGEMENT
cardiovascular reserve dysfunction
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Pulmonary HTN
Both pre & post-capillary components
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HFpEF may be conceived as a fundamental disorder of cardiovascular reserve function—Diastolic, Systolic, Chronotropic, Vascular.
HFnEF-CONCEPTS AND MANAGEMENT
Exaggerated hypertensive ageingMany of the abnormalities are noted with
normal ageing and are simply more markedly abnormal in HFpEF
HFnEF-CONCEPTS AND MANAGEMENT
DiagnosisSigns and/or symptoms of HF, Evidence of normal systolic LV function, Evidence of diastolic LV dysfunction or of
surrogate markers of diastolic LV dysfunction such as LV hypertrophy, LA enlargement, plasma levels of natriuretic peptides (NP)
HFnEF-CONCEPTS AND MANAGEMENT
C/F Framingham criteria
HFnEF-CONCEPTS AND MANAGEMENT
2 major criteriA OR 1 major criteriA plus 2 minor criteria
Diagnostic value of symptoms and signs
HFnEF-CONCEPTS AND MANAGEMENT Brunner-La Rocca [41] and Schweiz Me Forum2007;7(Suppl. 39):3–14 S
EVALUATION OF DIASTOLIC FUNCTION
HFnEF-CONCEPTS AND MANAGEMENT
DD INDICESMITRAL B BUMPIVRTMITRAL INFLOW – E, AMITRAL ANNULAR VELOCITIES- Mitral inflow propagation velocity -VP
Pulmonary Venous Doppler Flow into LA – SYSTOLIC (S), DIASTOLIC (D) , ATRIAL REVERSAL
(Ar),
HFnEF-CONCEPTS AND MANAGEMENT
Two-Dimensional EchocardiographyThe combination of Thickened left ventricular walls, Left atrial dilation, Absence of mitral valve disease Strong evidence of diastolic dysfunction and
elevated left ventricular diastolic pressure.
HFnEF-CONCEPTS AND MANAGEMENT
The normal rate of mitral valve closure after atrial systole is smooth and of brief duration.
Pts with increased LVEDP Onset of closure is premature Notch in between A and C Prolonged AC wave with a B bump
Sign is low sensitivity but high specificity for LVEDP(LAP) > 20 mmhg
Mitral B – bump
HFnEF-CONCEPTS AND MANAGEMENT
M-Mode Echocardiography
HFnEF-CONCEPTS AND MANAGEMENT
Mitral inflow patternsPulmonary vein flow
Doppler Evaluation of Diastolic Function
HFnEF-CONCEPTS AND MANAGEMENT
Transmitral Doppler Inflow
E velocity, A velocity, E/A deceleration time (DT) IVRT.
HFnEF-CONCEPTS AND MANAGEMENT
E -PEAK EARLY FILLING VELOCITY
A – PEAK FILLING VELOCITY DURING ATRIAL
SYS
E/A –LA-LV GRADIENT IN EARLY AND LATE
DIASTOLE.
DT –TIME INTERVAL FROM EARLY PEAK
INFLOW (E) TO CESSATION OF RAPID FILLING
PHASE.
A WAVE DURATION- ALONG WITH Pva
REFLECTS LV FILLING PRESSURES
HFnEF-CONCEPTS AND MANAGEMENT
A=83CM/S
E/A=1.4E=123c
m/s HFnEF-CONCEPTS AND MANAGEMENT
1.E -PEAK EARLY FILLING VELOCITY
2. A – PEAK FILLING VELOCITY DURING
ATRIAL SYS
3.E/A –LA-LV GRADIENT IN EARLY AND
LATE DIASTOLE.
4.DT –TIME INTERVALFROM EARLY PEAK
INFLOW (E) TO CESSATION OF RAPID
FILLING PHASE.
INVERSLY PROPORTIONAL TO CHAMBER
STIFFNESS.
5. A WAVE DURATION-ALONG WITH Pva
REFLECTS LV FILLING PRESSURES
DT=148ms
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
Limitations :
A large number of factors can affect the transmitral flow including age, heart rate, heart rhythm, loading conditions, LV systolic function, atrial function, and mitral valve disease.
TM flow cannot be used in isolation to assess diastolic function.
HFnEF-CONCEPTS AND MANAGEMENT
Valsalva ManeuverValsalva maneuver decreases preload during
the strain phase, pseudonormal mitral inflow changes to a pattern of impaired relaxation.
Mitral E velocity decreases with a prolongation of DT, whereas the A velocity is unchanged or increases, such that the E/A ratio decreases.
A decrease of 50% in the E/A ratio is highly specific for increased LV filling pressures.
HFnEF-CONCEPTS AND MANAGEMENT
IVRT
Normal – 70-90 ms.
HFnEF-CONCEPTS AND MANAGEMENT
IVRT lengthens - impaired LV relaxation shortens - LV compliance is decreased and LV
filling pressures increase.
IVRT varies with HR, preload and ventricular fn.
HFnEF-CONCEPTS AND MANAGEMENT
Pulmonary Venous Doppler Flow
right upper pul vein > 0.5 cm into the pul
vein End-expiration Sweep speed of 50 to
100 mm/s Average of 3 values
HFnEF-CONCEPTS AND MANAGEMENT
Measurements of pulmonary venous waveforms include
Peak systolic (S) velocity- S1,S2 in bradycardiaPeak anterograde diastolic (D) velocity,The S/D ratio – stages of diastolic dysfunction.Systolic filling fraction (S TVI/[S TVI + D TVI])Peak Ar velocity late diastole ,Duration of the Ar increases with increasing filling
pressures(Ar – A ) most sensitive and earliest indicator
elevated LV filling pressures. = LVEDPHFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
S wave -54.3 cm/sec
HFnEF-CONCEPTS AND MANAGEMENT
D = 74.2cm/sec
S/D<1
HFnEF-CONCEPTS AND MANAGEMENT
Ar vel = 36cm/s
HFnEF-CONCEPTS AND MANAGEMENT
Ar=130msAr-A=130-106=24ms
HFnEF-CONCEPTS AND MANAGEMENT
Normal values-
Peak S wave velocity: 60 ± 15 cm/sec.
Peak D wave velocity: 40 ± 15 cm/sec.
Peak S / Peak D ratio: 1.3 – 1.5 ( ± 0.3).
Systolic fraction= 60 – 68 ±10%
Peak Ar wave velocity: -32 ± 10 cm/sec.
Ar duration: 137 ± 31 msec.
Ar – A : < 30 msec
HFnEF-CONCEPTS AND MANAGEMENT
An Ar velocity >35 cm/sec & a difference in duration ( Ar – A ) >30 msec, is higly predictive of a LVEDP > 15 mm Hg.
Major limitation is difficult to obtain and influence by rhythm distrubances
HFnEF-CONCEPTS AND MANAGEMENT
Color M-Mode
Vp - the slope of the first aliasing velocity during early filling, measured from the MV plane to 4 cm into the LV or the slope of the transition from no color to color.
mitral inflow propagation velocity
Normal Values: Vp>5O cm/s(< 45 is abnormal in adults)
PCWP = [5.27 x E/Vp] + 4.6 (in mmHg)
(5.27X 123/33.5)+4.6 = 23.5
E/Vp > 2.5 to predict PCWP >15 mm Hg.
E/Vp ratio for the prediction of LV filling pressures in
patients with normal Efs should be cautious . (Vp may
be normal in pts with normal EF)
HFnEF-CONCEPTS AND MANAGEMENT
AFFECTED BY-
LV GEOMETRY
CHAMBER VOL
REGIONAL DYSSYNCHRONY
SYS FUNCTION
NEVER IN ISLOATION
HFnEF-CONCEPTS AND MANAGEMENT
Tissue Doppler Imaging (e’)
•Apical 4 chamber view•Positioned at or 1 cm within the septal and lateral insertion sites of the mitral leaflets•Sweep speed of 50 to 100 mm/s •end-expiration•average of 3•For mean take both medial and lateral annulus sites
HFnEF-CONCEPTS AND MANAGEMENT
systolic (S), early diastolic(Ea, Em, E’, e’, and
late diastolic velocities(Aa,Am, A’, or a’).
e’/a’ , E/e’ , TE-e’ .
e' is determined by LV relaxation,
preload (minimally)
a’ is determined by LA systolic function and
LvEDP HFnEF-CONCEPTS AND MANAGEMENT
e’The velocity of mitral annular movement
during early diastole, designated as e′ or E′ velocity.
correlates well with invasive measures of the time constant of myocardial relaxation tau .
In healthy young individuals, septal e′ is >10 cm/s and lateral e′ >15 cm/s at rest.
HFnEF-CONCEPTS AND MANAGEMENT
E/e’ , Normal-5-10 cm/secPredicts lv filling pressure- LAP - PCWP
HFnEF-CONCEPTS AND MANAGEMENT
E/e’Limitations
Different cardiac cyclesAge,preload,sys functionProsthetic valvesAnnular rings ---- DECREASE e’Annular calcificationSevere primary MR – increase e’ so, IVRT/E-e’
used
HFnEF-CONCEPTS AND MANAGEMENT
IVRT/Te −E′
The ratio of IVRT/Te′−E was inversely related to mean wedge pressure (and LA pressure) in patients with high filling pressures.
The concept was evaluated in patients with mitral disease and atrial fibrillation.
The major limitation to this method is the need to measure 3 time intervals from different cardiac cycles.
IVRT/TE-e’ <2 indicates increased LAP.
HFnEF-CONCEPTS AND MANAGEMENT
QRS TO e’
458msHFnEF-CONCEPTS AND MANAGEMENT
T e’-E =
21
E/e’
> 158 –15
< 8
LVEDP > 12
LVEDP N Normal LV FMitral valve
diease
IVRT/ TE-e’ < 2
YesNo
TISSUE DOPPLER ANNULAR DIASTOLIC VELOCITIES
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
QRS TO E
479msHFnEF-CONCEPTS AND MANAGEMENT
Stages of DHF
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
Diastolic Stress Test
E/e ´ ratio remains unchanged or is reduced-NORMAL E/e´ratio increases - impaired myocardial relaxation
Exercise is usually performed using a supine bicycle protocol,
HFnEF-CONCEPTS AND MANAGEMENT
In patients with diastolic heart failure, LA pressure is increased, leading to an increase in mitral E velocity, whereas annular e′ velocity remains reduced given the limited preload effect on e′.
On the other hand, in the absence of cardiac disease, e′ increases to a similar extent to the increase in mitral E velocity, and the normal E/e′ ratio essentially is unchanged with exercise.
HFnEF-CONCEPTS AND MANAGEMENT
Twisting and untwisting Twisting and untwisting of the LV are important aspects of cardiac
mechanics and function.
The apical portion of the LV normally twists counterclockwise and
the basal segment twists clockwise during systole, storing potential
energy.
The LV untwists immediately after systolic contraction,
contributing to generating an intraventricular pressure gradient.
LV torsion is the summation of the apical and the basal twisting.
measure twist using TDI and STE from short-axis images of the LV
These studies showed that torsion and circumferential strain are
normal in patients with diastolic heart failure whereas longitudinal
and radial deformation are reduced.HFnEF-CONCEPTS AND MANAGEMENT
MRIAcquire images in any selected plane or along
any selected axis. This makes CMR the gold standard for LV volume, LA volume, and LV mass measurements.
MR can provide a whole range of LV filling parameters which are identical or nearly identical to those obtained with echocardiography.
CMR constitutes not only a valid alternative to echocardiography but could also be the first-choice technique if small changes in LA or LV volumes and in LV mass are expected.
Several morphological and functional parameters such as tissue characterization or LV diastolic untwisting can only be assessed by CMR
HFnEF-CONCEPTS AND MANAGEMENT
NPNPs may be much less useful in this condition:
Increased wall stress is the stimulus for NP production and release from the cardiomyocyte, but, according to La-Place’s law, wall stress may be normal in a non-dilated, hypertrophied ventricle.
Under these circumstances, NPs may mainly originate from the atria, explaining the common finding of only marginally elevated BNP or NT-proBNP levels despite highly symptomatic patients.
NPs rise sharply once atrial fibrillation occurs, further underpinning the poor diagnostic value of these markers.
HFnEF-CONCEPTS AND MANAGEMENT
Cardiac catheterizationSimultaneous right & left heart
catheterization can be useful in total hemodynamic assessment including elevated LV pressures & CO.
Coronary angiography will help us to diagnose significant CAD.
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
Diagnostic guidelines
HFnEF-CONCEPTS AND MANAGEMENT
When comparing these 4 sets of diagnostic guidelines, it becomes evident that the mere presence of signs or symptoms of HF and a normal LVEF never sufficed to firmly establish the diagnosis of HFNEF, which always required additional evidence of diastolic LV dysfunction, LA size, or LV mass.
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
Natural HistoryMortality - Allcause mortality for HFnlEF is
similar to that of HF with a reduced EF.HF patients with normal EF more often died
of noncardiovascular causes, whereas deaths due to coronary disease were less frequent.
HFnEF-CONCEPTS AND MANAGEMENT
Framingham Heart Study, for patients with HFNEF the annual mortality was 8.7% compared with 3% in matched controls and for SHF was 18.9% compared with a 4.1% in age- and sexmatched controls over 6.2 years.
HFnEF-CONCEPTS AND MANAGEMENT
Management Two objectives
Treat the presenting syndrome of HF— Relieve resting or exercise-associated venous
congestion and Eliminate precipitating factors.
Reverse the factors responsible for diastolic dysfunction or other perturbations that lead to HFnlEF
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
Age 60 yearsCurrent HF symptoms
LVEF 0.45
NYHA Class III/IV
Echo (LVH, LAE)
ECG (LVH, LBBB)
CXR congestion
I-PRESERVE
NYHA class II - IV
CHF hosp. 6 months
Key Exclusions: SBP >160 mm Hg; prior EF <40%; ACS or stroke ≤ 3m, hypertrophic or restrictive CM, pericardial or valvular disease, significant pulmonary disease, creatinine >2.5, Hb <11
HFnEF-CONCEPTS AND MANAGEMENT
Months from Randomization
Cu
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rim
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Eve
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(%
)40 -
0 -
10 -
20 -
30 -
0 6 12 18 24 36 4230 48 6054
20671929 18121730 1640 1513 12911569 1088 497816206119211808 1715 1618 1466 12461539 1051 446776
No. at RiskIrbesartanPlacebo
HR (95% CI) = 0.95 (0.86-1.05)Log-rank p=0.35 Placebo
Irbesartan
HFnEF-CONCEPTS AND MANAGEMENT
Hong Kong Diastolic Heart Failure study Diuretics, Diuretics + Irbesartan, or
Diuretics + Ramipril were used. At the end of one year Irbesartan & Ramipril
groups were better than diuretics alone in reducing BNP & improving LV systolic & diastolic function.
Although quality of life & SBP & DBP were similar in all 3 groups
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
HFnEF-CONCEPTS AND MANAGEMENT
DiureticsMainstay of symptomatic treatment.Loop diuretics are preferred as they are more
potent compared with thiazides.Diuretics should be initiated at lower doses
and gradually up-titrated to maintenance doses.
However, patients with HFNEF are typically very sensitive to relatively small changes in blood volume and care must be taken to avoid hypotension.
HFnEF-CONCEPTS AND MANAGEMENT
Statins
Possible Mechanisms• Beneficial effects of statins in patients with
coronary artery disease, diabetes and impaired renal function which are common in patients with diastolic HF.
• Beneficial effects on LV hypertrophy and fibrosis.• Mild antihypertensive effect of statins.• Beneficial effect on endothelial function and
regression of aortic atherosclerosis.• Protective effect on LV remodeling.• Antiinflammatory and antioxidant effects.
HFnEF-CONCEPTS AND MANAGEMENT
Recently CORONA trial reported neutral outcome of statin therapy in the HFrEF patients of the.
HFnEF-CONCEPTS AND MANAGEMENT
Spirinolactone TOPCAT Aldosterone in Diastolic HF (ALDO-DHF)
the role of spironolactone versus placebo is being studied to elucidate if an anti-fibrotic intervention strategy is adequate to improve the outcome in HFNEF.
Long-term aldosterone receptor blockade with spironolactone improved diastolic function but did not affect clinical symptoms or exercise capacity.
HFnEF-CONCEPTS AND MANAGEMENT
DecompensationTriggers
Uncontrolled hypertensionIncreased salt and water intake and/or
retentionTachyarrhythmiasIschemiaChronic kidney diseaseAnemiaChronic lung diseaseInfection
HFnEF-CONCEPTS AND MANAGEMENT
ACC/AHA Heart Failure Guidelines HFNEF
Recommendation Class
Control systolic and diastolic hypertension I
Ventricular rate control in patients with atrial fibrillation I
Diuretics to control congestion and edema I
Coronary revascularization is reasonable in patients with symptomatic coronary artery disease
IIa
Restoration and maintenance of sinus rhythm in patients with atrial fibrillation might be useful to improve symptoms
IIb
Beta-blocking agents, ACE inhibitors, AT II receptor blockers, or calcium antagonists might be effective to minimize symptoms
IIb
The use of digitalis is not established IIb
Hunt et al. ACC/AHA Practice Guidelines JACC 2005;46:1-82HFnEF-CONCEPTS AND MANAGEMENT
HFSA Guidelines
HFnEF-CONCEPTS AND MANAGEMENT
Novel therapiesNovel strategies should try to interfere with
HFNEF-specific myocardial signal transduction pathways, which account for Prominent cardiomyocyte hypertrophy, Down-regulation of MMPs, Up-regulation of TIMPs, Hypophosphorylation of stiff titin isoforms, Substrate shifts from glucose to free fatty
acids.
HFnEF-CONCEPTS AND MANAGEMENT
Novel therapiesCyclic GMP Modulator
Reduce ventricular –vascular stiffening,Antagonize maladaptive chamber
remodelling,Improve endothelial function,Reduce pulmonary vascular resistance,Enhance renal responsiveness to NP.
HFnEF-CONCEPTS AND MANAGEMENT
Sildenafil
Patients with HFPEF, phosphodiesterase-5 inhibition with administration of sildenafil for 24 weeks, compared with placebo, did not result in significant improvement in exercise capacity or clinical status.
HFnEF-CONCEPTS AND MANAGEMENT
Rho-kinase inhibitors such as fasudil and Y-27632 have vasorelaxation properties and have demonstrated the ability to blunt progression of hypertrophic remodelling in animal models of HF.
Alagebrium chloride (ALT-711) is a novel compound that breaks glucose cross-links and improves ventricular and arterial compliance in animals.
Acute modification of titin PKG phosphorylation sites may dynamically modulate titin stiffness.
The anti-anginal drug ranolazine blocks inward sodium Current, thereby reducing intracellular calcium, and it has also been suggested as a potential treatment for HFpEF,although human HFpEF data are currently unavailable.
HFnEF-CONCEPTS AND MANAGEMENT
HFNEF syndrome is a heterogenous entity with high prevalence and mortality rates almost as high as that of systolic HF.
It is a relatively common cause of HF in the elderly and has a variety of causes and pathophysiological mechanisms.
Despite improvements in its understanding, many questions remain and, as yet, there are no treatments of any proven benefit. Ongoing trials are underway.
HFnEF-CONCEPTS AND MANAGEMENT