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HeartFailure- SystolicvsDiastolic CHRISTUSSpohn HeartInstitute InnovationsinCardiovascularCare CorpusChristi,Texas 6/09/17 RaymondStainback,MD,FACC,FASE MedicalDirector,NoninvasiveCardiology TexasHeart© InstituteatBaylorSt.Luke’sMedicalCenter Assoc.Prof.ofMedicine,BaylorCollegeofMedicine Houston,TX Case1. • • • • • • • • • • • • 52yr maleACinstallerfollowedforDCMfor6yrs - PARTA Obesity,bingealcohol,marriedsteadyworker Otherwise‘healthy’6’4”- 275lbs Onoriginalpresentation,HTN,LEedema,FCIIDOE InitialEcho- dilatedLV(LVEDvol index85ml/m2),LVEF40% GuidelinesbasedMedicaltherapyinitiated(ACE-I,bb,diuretic) Patientverypoorlycompliantx3yrs Avoideddiuretics(hardtowork),casualattitude,intermittentARB compliance(ACE-Iintolerant,fatigueandhypotension) NewA.fibwithRVRà FCIII-IVsymptoms- DCCV,morecompliant withGBMT;LVEF25-29%(LHCneg CAD), LifeVestplaced--after2weekslatersuccesful therapyforVT/VF arrest SecondarypreventionAICDimplanted. Didwellfor2years--recurrentAICDshocksà amio /mexilitine Case1. • • • • • • • • • • • • 52yr maleACinstallerfollowedforDCMfor6yrs - PARTB Patientdidwellforanotheryear SuddenlyadmittedtooutsidehospitalforrecurrentICDshocks AtlocalED,LVEF<20%,7recentshocksrecorded. EPrecommendedVTablationtherapy. Patientelectedtransferbacktoourfacility. EchoconfirmedmoreseverelydilatedLV(LVEDvol >300ml) LVOTstrokevolume45ml(CardiacIndex=1.2ml/min/m2(nl 2.5) AtHR=80bpm RepeatLHC- neg Cor - PCWP34mmHg Diuresis,IVinotropesx2weeks. DestinationtherapyLVADplanned(receivedHMII-1yr ago) Case1.EchoduringIVdobutamine HFrEF - HFReducedEjectionFraction 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure Developed in Collaboration With the American Academy of Family Physicians, American College of Chest Physicians, and International Society for Heart and Lung Transplantation Treatment of HFrEF Stage C and D †Hydral-Nitrates green box: The combination of ISDN/HYD with ARNI has not been robustly tested. BP response should be carefully monitored. ‡See 2013 HF guideline. §Participation in investigational studies is also appropriate for stage C, NYHA class II and III HF. ACEI indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor-blocker; ARNI, angiotensin receptor-neprilysin inhibitor; BP, blood pressure; bpm, beats per minute; C/I, contraindication; COR, Class of Recommendation; CrCl, creatinine clearance; CRT-D, cardiac resynchronization therapy–device; Dx, diagnosis; GDMT, guideline-directed management and therapy; HF, heart failure; HFrEF, heart failure with reduced ejection fraction; ICD, implantable cardioverter-defibrillator; ISDN/HYD, isosorbide dinitrate hydral-nitrates; K+, potassium; LBBB, left bundle-branch block; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NSR, normal sinus rhythm; and NYHA, New York Heart Association. Case2. • 88yr oldfemalewith6yearhx oftypicalFCII-IIIHF symptoms,livinginherhomewithhiredcaregiver, familynearby.PARTA • Permanenta.fib • Hx smallremoteCVA • Chronicpelvicpain(idiopathic) • CKDstageIII(Cr1.7à 2.7duringHFexacerbations) • SSSs/pPPM- VVI(100%RVpaced) • ASs/premotebioprosthetic AVR •• RemotetobaccomoderateCOPDwithelevatedPAP(60 BP104/62mmHgHR104ht 68”170lbs (BSA1.9) • mmHgrange) SaO2100%onRA •• (neg DM,HTN) JVPelevated,lungs‘clear’ Case2. • 88yr oldfemalewith6yearhx oftypicalFCII-IIIHF symptoms,livinginherhomewithhiredcaregiver, familynearby.PARTB • 3yearsago,patientadmittedwithacuteHFexacerbation approximatelyeverymonthx18mo’s • Nosignif LEedema,butabdominalbloating,increased weight,unresponsivetousualoraldiuretic. • Cachexiaduetopoorappetite,hepaticcongestion. • FunctionalTRworsening. •• WastoldtoseekHospicecareà BP104/62mmHgHR104htdeclinedànext 68”170lbs (BSA1.9) • exacerbationinstructedambulancetodivetoourfacility. SaO2100%onRA • JVPelevatedtoTemplewithprominentsystolicwave, lungsmildcrackles,mildkyphosis,cachexia,abd distention,noLEedema. Case2. • 88yr oldfemalewith6yearhx oftypicalFCII-IIIHF symptoms,livinginherhomewithhiredcaregiver, familynearby.PARTC • Patienthospitalizedx2weeks • LowdoseIVdobutamine forRVfailure • IVloopdiuretic. • ContinueonlowdoseNOACfora.fib.LowdoseACE-I graduallydiresed 15lbs,feltbetter. • Effectivenessoforalloopdiureticreturned •• Patientadmittedonlytwiceoverthenextyearduetoa BP fall(ribfracture)andepisodeofUTI;milddementia- still athome. • HomecaregiverseducatedonSalt,medicalcompliance, Dailyweights(withdiureticadjustment) • OnerecentexacerbationoftrueHF2weeksago Case2. HFpEF - HFpreseved EjectionFraction Case2. HFpEF - HFpreseved EjectionFraction Ambar Afshar Andrade, MD FACC Advanced Heart Failure, Mechanical Circulatory Support, and Transplant Cardiology Advocate Christ Medical Center Oak Lawn, IL Definitions Heart failure with preserved LVEF (HFpEF) is a clinical syndrome in which: ¡ ¡ symptoms and signs of HF normal or near normal left ventricular ejection fraction (LVEF >50 percent), This is contrasted with heart failure with reduced ejection fraction (HFrEF) in which the LVEF is reduced Definitions Previously, HFpEF was termed “diastolic HF” and HFrEF was described as “systolic HF” “Diastolic HF” is a suboptimal term: ¡ ¡ suggests a single underlying mechanism several alternative and complementary pathophysiologic mechanisms exist in HFpEF ¢ ¢ ¢ ¢ longitudinal LV systolic dysfunction (despite a normal EF) abnormal ventricular-arterial coupling abnormal exercise-induced vasodilation chronotropic incompetence Definitions Diastolic dysfunction and HFpEF are not synonymous -pts invariably HAVE distolic dysfnx Diastolic dysfunction refers to abnormal mechanical properties of the ventricle This is a functional abnormality of diastolic relaxation, filling, or distensibility of the LV, regardless of whether the patient is symptomatic or not HFpEF denotes the signs and symptoms of clinical HF in a patient with a normal LVEF Definitions Evidence of DD is nearly universal in HFrEF (“systolic HF”) DD is not unique to diastolic HF A Oktay, S Shah, Current Cardiology Reviews, 2015, 11, 42-52 Background HFpEF currently accounts for more than 50% of all heart failure Prevalence relative to HFrEF in rising Prevalence is greater in the elderly and women Comorbidities Hypertension Aging CAD Diabetes mellitus OSA Obesity Kidney disease Atrial fibrillation Comorbidities Atrial ¡ ¡ fibrillation more common in HFpEf than HFrEF loss of atrial contraction can dramatically reduce LV filling and increase LAP Elevated ¡ BP increased wall stress can impair myocardial relaxation Ischemia ¡ worsens diastolic dysfunction Pathophysiology Diastolic Dysfunction resulting from LVH and changes in extra-celluar matrix (CAD,age,DM) ¡ ¡ Reduced rate of diastolic relaxation Increased chamber stiffness Pathophysiology Systolic ¡ ¡ Dysfunction despite normal LVEF, tissue Doppler and strain imaging show subtle abnormalities in systolic function These abnormalities are accentuated with exercise Chronotropic ¡ ¡ competence is depressed compared to age matched controls likely related to deficits in β-adrenergic stimulation due to increase plasma catecholamine's Pathophysiology Abnormal ¡ ¡ ventricular-arterial coupling vascular stiffening occurs with age, DM and HTN reduced aortic dispensability in HFpEF is strongly associated with impaired exercise tolerance Endothelial ¡ ¡ dysfunction HFpEF greater degree of endothelial dysfunction severity of dyspnea and fatigue with exercise is correlated with degree of flow-mediated vasodilatation impairment Differential Diagnosis Restrictive Cardiomyopathy ¡ Amyloidosis ¡ Hemochromatosis Hypertrophic Cardiomyopathy ¡ HCM (sarcomere gene mutation) Valvular Disease ¡ Stenosis or Regurgitation Differential Diagnosis Right Heart Failure ¡ ¡ ¡ Pericardial Disease ¡ ¡ PH RV infarct ARVC Cardiac tamponade Constrictive pericarditis Obstructive lesions ¡ ¡ Atrial myxoma Pulmonary vein stenosis Diagnosis Signs and symptoms similar to HFrEF ¡ ¡ ¡ ¡ ¡ Labs ¡ BNP ECG ¡ DOE, PND, orthopnea Fatigue Elevated JVD Pulmonary rales LE edema LVH, prior infarct, atrial fibrillation CXR ¡ cardiomegaly, pulmonary edema Diagnosis Detailed echocardiogram Consider evaluation for CAD CAD prevalence 50% in patient with HFpEF ¡ presence of CAD associated with increased mortality among HFpEF patients ¡ symptoms of CAD can mimic HF ¡ some advocate routine angiography in all patients with HFpEF ¡ EMBx ¡ may be helpful in selected patients with evidence for restrictive or hypertrophic CM Consider CMR Signs and Symptoms of Heart Failure Normal LVEF > 50% Diagnosis Evidence for Abnormal Relaxation, Diastolic Filling or Elevated Filling Pressures Invasive Hemodynamic Measures TD TD Biomarkers E/e’ > 15 15>E/e’>8 BNP > 200 PCWP > 12 mmHg LVEDP > 16 mmHg Biomarkers Echo-Doppler BNP > 200 E/A < 0.5 and DT > 280 ms or LAVI > ml / m2 HFpEF Paulus WJ, et al. Eur Heart J 2007;28:2539–2550 European Study Group on Diastolic Heart Failure. Eur Heart J 1998;19:990–1003 Defining diastolic heart failure: a call for standardized diagnostic criteria. Circ 2000;101:2118–2121 Yturralde RF, et al. Diagnostic criteria for diastolic heart failure. Prog Card Dis 2005;47:314–319 Treatment Patients with HFpEF often exhibit chronotropic incompetence β - blockers can contribute to excessive bradycardia Failure to augment HR during activity can limit cardiac output and contribute to dyspnea and fatigue Management of β-blockers therapy requires attention to HR at rest and with activity Treatment Diuretics ¡ ¡ Nitrates ¡ ¡ necessary to treat volume overload administered with caution to avoid excessive preload reduction and hypotension evidence of efficacy is lacking randomized trial found ISMN tended to reduce activity in patients with HFpEF Phosphodiesterase 5 inhibitors beneficial hemodynamic response to sildenafil in a single center trial ¡ finding not confirmed in the RELAX trial ¡ Digoxin a parallel study to the DIG trial evaluated the role of digoxin in 988 patients with HF and an LVEF >45 percent ¡ no effect on all-cause mortality or all-cause cardiovascular hospitalization ¡ Treatment Standard HF care ¡ ¡ ¡ ¡ HF education daily weights management of poly-pharmacy close contact with HF team High risk patients – aggressive treat co-morbid conditions ¡ ¡ ¡ ¡ ¡ ¡ ¡ CAD hyperlipidemia DM HTN obesity OSA and lung disease Atrial fibrillation Treatment Diuretics necessary for management of volume overload Once euvolemic, minimize loop diuretics to prevent over-diuresis and sympathetic activiation ACEI, ARB’s, β – Blockers and digoxin all failed to show significant benefit Agents still beneficial in management of HTN Reasonable to use spironolactone to treat patients with HFpEF resembling those in the America’s enrolled in TOPCAT Outcomes Morbidity outcomes in HFrEF and HFpEF are similar These include: ¡ ¡ ¡ ¡ ¡ rate and frequency of hospitalization for HF symptomatic status as measured by abnormalities in myocardial oxygen consumption six minute walk distance Minnesota Living with Heart Failure questionnaire scores other quality of life indicators Patients with HFpEF have a morbidity burden equivalent to that in patients with HFrEF Summary Multiple mechanisms beyond diastolic dysfunction exist for HFpEF ¡ ¡ ¡ ¡ ¡ sub-clinical LV dysfunction abnormal ventricular-arterial coupling abnormal exercise-induced vasodilatation extra-cardiac volume overload chronotropic incompetence More common in elderly and women Signs and symptoms identical to HFrEF Summary Rule-out other causes of HF signs and symptoms with normal EF Diagnosis requires: signs and symptoms of HF ¡ normal LVEF ¡ evidence for abnormal relaxation, diastolic filling or elevated filling pressures ¡ Aside for spironolactone, specific pharmacologic therapy unproved Morbidity and mortality are high and similar to HFrEF Aggressively treat co-morbidities 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure Developed in Collaboration With the American Academy of Family Physicians, American College of Chest Physicians, and International Society for Heart and Lung Transplantation Pharmacological Treatment for Stage C HF With Preserved EF COR I I LOE B C Recommendations Systolic and diastolic blood pressure should be controlled in patients with HFpEF in accordance with published clinical practice guidelines to prevent morbidity Diuretics should be used for relief of symptoms due to volume overload in patients with HFpEF. Comment/ Rationale 2013 recommendation remains current. 2013 recommendation remains current. Pharmacological Treatment for Stage C HF With Preserved EF COR IIa IIa IIa LOE C C C Recommendations Coronary revascularization is reasonable in patients with CAD in whom symptoms (angina) or demonstrable myocardial ischemia is judged to be having an adverse effect on symptomatic HFpEF despite GDMT. Management of AF according to published clinical practice guidelines in patients with HFpEF is reasonable to improve symptomatic HF. The use of beta-blocking agents, ACE inhibitors, and ARBs in patients with hypertension is reasonable to control blood pressure in patients with HFpEF. Comment/ Rationale 2013 recommendation remains current. 2013 recommendation remains current. 2013 recommendation remains current. Pharmacological Treatment for Stage C HF With Preserved EF COR IIb IIb LOE B-R B Recommendations In appropriately selected patients with HFpEF (with EF ≥45%, elevated BNP levels or HF admission within 1 year, estimated glomerular filtration rate >30 mL/min, creatinine <2.5 mg/dL, potassium <5.0 mEq/L), aldosterone receptor antagonists might be considered to decrease hospitalizations. The use of ARBs might be considered to decrease hospitalizations for patients with HFpEF. Comment/ Rationale NEW: Current recommendation reflects new RCT data. 2013 recommendation remains current. Pharmacological Treatment for Stage C HF With Preserved EF COR LOE III: No Benefit B-R III: No Benefit C Recommendations Routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or QoL in patients with HFpEF is ineffective. Routine use of nutritional supplements is not recommended for patients with HFpEF. Comment/ Rationale NEW: Current recommendation reflects new data from RCTs. 2013 recommendation remains current.
