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IL CARDIOLOGO AMBULATORIALE E L’IMAGING INTEGRATO NELLO SCOMPENSO CARDIACO CRONICO: A CHE PUNTO SIAMO?
Luigi Tarantini Fellow ANMCO
UOC Cardiologia – Dip. Medicina Specialistica Ospedale “San Martino”ULSS n°1 - Belluno
Stages, Phenotypes and Treatment of HF
STAGE AAt high risk for HF but
without structural heart
disease or symptoms of HF
STAGE BStructural heart disease
but without signs or
symptoms of HF
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Prevent hospitalization
· Prevent mortality
Strategies
· Identification of comorbidities
Treatment
· Diuresis to relieve symptoms
of congestion
· Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
· Revascularization or valvular
surgery as appropriate
STAGE CStructural heart disease
with prior or current
symptoms of HF
THERAPYGoals· Control symptoms· Patient education· Prevent hospitalization· Prevent mortality
Drugs for routine use· Diuretics for fluid retention· ACEI or ARB· Beta blockers· Aldosterone antagonists
Drugs for use in selected patients· Hydralazine/isosorbide dinitrate· ACEI and ARB· Digoxin
In selected patients· CRT· ICD· Revascularization or valvular
surgery as appropriate
STAGE DRefractory HF
THERAPY
Goals
· Prevent HF symptoms
· Prevent further cardiac
remodeling
Drugs
· ACEI or ARB as
appropriate
· Beta blockers as
appropriate
In selected patients
· ICD
· Revascularization or
valvular surgery as
appropriate
e.g., Patients with:
· Known structural heart disease and
· HF signs and symptoms
HFpEF HFrEF
THERAPY
Goals
· Heart healthy lifestyle
· Prevent vascular,
coronary disease
· Prevent LV structural
abnormalities
Drugs
· ACEI or ARB in
appropriate patients for
vascular disease or DM
· Statins as appropriate
THERAPYGoals· Control symptoms· Improve HRQOL· Reduce hospital
readmissions· Establish patient’s end-
of-life goals
Options· Advanced care
measures· Heart transplant· Chronic inotropes· Temporary or permanent
MCS· Experimental surgery or
drugs· Palliative care and
hospice· ICD deactivation
Refractory symptoms of HF at rest, despite GDMT
At Risk for Heart Failure Heart Failure
e.g., Patients with:
· Marked HF symptoms at
rest
· Recurrent hospitalizations
despite GDMT
e.g., Patients with:
· Previous MI
· LV remodeling including
LVH and low EF
· Asymptomatic valvular
disease
e.g., Patients with:
· HTN
· Atherosclerotic disease
· DM
· Obesity
· Metabolic syndrome
or
Patients
· Using cardiotoxins
· With family history of
cardiomyopathy
Development of
symptoms of HFStructural heart
disease
But also…Rheumatological/Connective Tissue DisordersRenal Insufficiency
Exercise-induced
diastolic dysfunction
End point: exercise
capacity
Volume overload
End point: E/e’, NP,
hospitalizations
Pulmonary hypertension
RV failure
End point: PAP,
hospitalizations
Nebivololcarvedilol?
ACE-ARB?
DASH diet?
MRI: COR I(GUCH,RVEF,…)
ESC GL
MRICOR I
LV function
Etiology
Treatment
Fonarow G. et Al. JACC 2007
Optimize Registry: N = 41,267
Chronic heart failure: one disease with a wide but continuous spectrum of phenotypes.
Systemic Hypertension and HF Phenotype
Osservatorio CV - Trieste 2009-2013, n=2610 (28%)
Centro CardiovascolareTrieste
HFpEF borderline
22%
HFpEF52%
HFrEF26%
CAD/Valvular/SH 17%
HFpEF borderline
14%
HFpEF74%
HFrEF12%
Valvular/SH 22%
HFpEF borderline
18%
HFpEF50%
HFrEF32%
CAD/SH 29%
HFrEF11%
HFpEF77%
HFpEF b12%
SH-HF phenotype 29%
“Heart Failure with Preserved Systolic Function is a descriptiveapproach that makes no assumptions about our knowledgeabout the pathophysiology of this disorder”(Burkoff D, Maurer MS, Packer M. Circulation 2003)
Differential diagnoses for heart failureand heart failure-like syndromes in the presence of a preserved LVEF
DHF (slowed LV relaxation ±increased chamber stiffness)
•Hypertensive cardiomyopathy
•Diabetic cardiomyopathy
•Hypertrophic cardiomyopathy
•Restrictive cardiomyopathy
•Infiltrative cardiomyopathy
•Cardiac storage disease
•Arterial hypertension
•Reduced aortic distensibility
•Unsuccessful ageing
Systolic LV dysfunction or otherclinical condition and Normal EF
•Reversible myocardial ischemia
•Severe valvular stenosis or
regurgitation
•Chronotropic incompetence
•Right-sided heart failure
•Cor pulmonale
•Mitral or tricuspid valve stenosis
•Atrial myxoma
•Constrictive pericarditis
Noncardiac causes of heart failure-like symptoms and signs
•Anemia•Thyrotoxicosis•Obesity•Pulmonary parenchymal disease•Pulmonary vascular disease•Renal disease•Hepatic disease•Chronic venous insufficiency•Medication adverse effects•Deconditioning
The relevance of ventricular-arterial interaction in HFPEF
• ↑end-systolic load
• ↑ventricular wall stress
• Ventricular relaxation
• ↑Ventricle mass
• ↑left atrial volume
• ↑Δ Blood Pressure
• Diastolic Blood Flow
• ↑ myocardial ischemiaRafey M. Clev. Clin. Med. J. 2009
CardiacInsult
Cardiac muscleDysfunction
VentricularDysfunction
Dilatationremodeling
pumpfailure
congestiveHeart failure
DEATH
De Keulenaer and Brutsaert , Progr Cardiovasc. Dis 2007
The vicious circle paradigm of CHF
A
B
CD
Architettura del miocardio ventricolare
sinistro
r
Strato miocardico esternoSotto-EPICARDICOfibre longitudinali
elica oraria
Strato miocardico internosotto-ENDOCARDICO
fibre longitudinali elica anti-oraria
Strato miocardico centraleCIRCONFERENZIALE (60%)
Lower R. Tractus de corde, Oxford, Univ. Press, 1932
Progressivo Aumento del Rischio di Scompenso Cardiaco
con l’aumento della Massa VS
Gottdiener JS. JACC 2000;35:1628
1,0 1,1
1,5
1,9
2,8
0,0
0,5
1,0
1,5
2,0
2,5
3,0
Ris
chio
Rel
ativ
od
i Sco
mp
enso
Car
dia
co
Q1 Q2 Q3 Q4 Q5
Quintili di Massa Ventricolare Sinistra (ECG)
5888 soggettiEtà > 65 anni
The Cardiovascular Health Study
0
1
2
3
4
Normal geometryEccentric
Hypertrophy
Verdecchia P et al., 1995, 1996
0
10
20
30
40
0
5
10
15
20
25
30
35
Krumholz HM et al., 1995 Koren MJ et al., 1991
10-year event rate (%) Events/100 patient-year
male
8-year event rate (%)
female
Normal LV mass Increased LV mass
Normal
Relative
Wall
Thickness
125 g/m2
0.45
Concentric
remodeling
Concentric
hypertrophy
Increased
Relative
Wall
Thickness
A B C D
Progression from hypertrophy to diastolic heart failure
Mandinov L. et Al. Cardiovasc. Res. 2000
83% of patients
showed a reductionof circunferentialand/or longitudinalLV systolic function
Am J Cardiol 2012; 109: 383
Early stage left ventricular dysfunction phenotypes in type II diabetic patients without known cardiac disease :
The DYDA study
43,8%21,5%
22,0%12,7%
Normal LV FunctionN =301
Isolated diastolicLV dysfunction
N =148
Isolated systolicLV dysfunction
N =151
Diastolic + SystolicLV dysfunction
N = 87LV dysfunction
N = 386
56,2%
European J. of Cardiovasc. Prev. & Rehab. In press
The clinical relevance of the impaired systolic functionin HFPEF
Bourlag B et Al. JACC 2009
• Echocardiography• Anatomy, morphology, ventricular function, ischemia/viability,
coronary flow, perfusion, LV synchronism, valvular
stenosis/regurgitation, …
• Nuclear Cardiology• Ventricular function, ischemia/viability, LV synchronism,
adrenergic function, …
• Cardiac Magnetic Resonance• Ventricular function, anatomy, morphology, perfusion, viability,
tissue characterisation, LV synchronism, angiography, …
• Cardiac Computed Tomography• Angiography, ventricular function, perfusion, tissue
characterisation
Cardiovascular Imaging in
Multimodality Enviroment
Conclusions
• Especially in Cardiology there is a continuing development in medical technologies expanding the available measurementswith overlapping capabilities
• The selection of which test to use and when in HF patientsshould be based on a broad perspective and expertknowledge of what each available technique can offer, itssafety, feasibility, costs and impact on clinical outcome.
• Appropriate multiparametric/multimodality imaging approachmay offer effective responses in the multiple critical issues stillpresent in the diagnosis, management and risk stratificationof HF patients.
“ Bisogna avere in sé il caos per partorire una stella che danzi.” Friedrich Nietzsche
Grazie dell’attenzione !!!!