Download Heart Failure with Preserved Ejection Fraction(HFpEF)

3/25/2015
Heart Failure with Preserved
Ejection Fraction
Attayeb Alameen
Nurse Specialist
Cardiovascular Disease Management Program
King Abdulaziz Cardiac Center
HEART FAILURE
A complex clinical syndrome that results
from any structural or functional
impairment of ventricular filling or
ejection of blood.
2013 ACCF/AHA Heart Failure Guideline
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Heart Failure
HF may be associated with a wide spectrum of
LV functional abnormalities, may range from:
 Patients with normal LV size and preserved EF
To
 Patients with severe dilatation and/or
markedly reduced EF.
2013 ACCF/AHA Heart Failure Guideline
Heart Failure
EF is considered important in classification of
patients with HF because of:
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Differing patient demographics
Comorbid conditions
Prognosis
Response to therapies
Most clinical trials selected patients based on EF
2013 ACCF/AHA Heart Failure Guideline
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Classification
Ejection Fraction
(EF)
Heart failure with reduced ejection fraction
(HFrEF)
• Formerly referred to as systolic heart
failure
< 40%
Heart failure with preserved ejection
fraction (HFpEF)
• Formerly referred to as diastolic heart
failure
> 50%
HFpEF borderline
41-49%
HFpEF improved (patients with a history of
HFrEF)
> 40%
Circulation 2013;128:e240-327.
Classification
Ejection Fraction
(EF)
Heart failure with reduced ejection fraction
(HFrEF)
• Formerly referred to as systolic heart
failure
< 40%
Heart failure with preserved ejection
fraction (HFpEF)
• Formerly referred to as diastolic heart
failure
> 50%
HFpEF borderline
41-49%
HFpEF improved (patients with a history of
HFrEF)
> 40%
Circulation 2013;128:e240-327.
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Heart Failure with Preserved
Ejection Fraction(HFpEF)
A clinical syndrome in which patients have:
 Symptoms and signs of HF
 Normal or near normal left ventricular (LV)
systolic function
 Normal LV chamber size
 Evidence of LV diastolic dysfunction(abnormal LV
filling and/or elevated filling pressures) .
1.Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure: Part I:
diagnosis, prognosis, and measurements of diastolic function. Circulation 2002; 105:1387
Prevalence
 (HFpEF) among patients with (HF)
varied widely approximately 50%
(range 40% to 71%)
2013 ACCF/AHA Heart Failure Guideline
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Euro heart Failure Survey
PREVALENCE AND DEMOGRAPHICS
 The prevalence of HFpEF increases with age.
 HF-PEF is more common in women than men.
In CHART study of over 19,000 Medicare
beneficiaries hospitalized with the principal
discharge diagnosis of HF.
Topol EJ, Traill TA, Fortuin NJ. Hypertensive hypertrophic cardiomyopathy of the elderly. N Engl J Med 1985; 312:277.
Masoudi FA, Havranek EP, Smith G, et al. Gender, age, and heart failure with preserved left ventricular systolic function. J Am Coll Cardiol 2003; 41:217.
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PREVALENCE AND DEMOGRAPHICS
The ADHERE database of more than 100,000
hospitalizations due to acute decompensated
HF, had the following clinical characteristics
compared to those with systolic dysfunction.
Yancy CW, Lopatin M, Stevenson LW, et al. Clinical presentation, management, and in-hospital outcomes of patients admitted with
acute decompensated heart failure with preserved systolic function: a report from the Acute Decompensated Heart Failure National
Registry (ADHERE) Database. J Am Coll Cardiol 2006; 47:76.
PREVALENCE AND DEMOGRAPHICS
 More likely to be older, female, and
hypertensive.
 Less likely to have had a prior myocardial
infarction.
 Lower in-hospital mortality (3 versus 4
percent) but similar ICU and hospital length of
stay.
Yancy CW, Lopatin M, Stevenson LW, et al. Clinical presentation, management, and in-hospital outcomes of patients admitted with
acute decompensated heart failure with preserved systolic function: a report from the Acute Decompensated Heart Failure
National Registry (ADHERE) Database. J Am Coll Cardiol 2006; 47:76.
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ETIOLOGY
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Chronic hypertension.
Hypertrophic cardiomyopathy (HCM).
Coronary heart disease.
Diabetic heart disease.
Restrictive cardiomyopathy.
Common Causes
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PATHOPHYSIOLOGY
Diastolic function is determined by two factors:
 The process of myocardial relaxation (which is an
active process that requires metabolic energy) .
 The compliance or distensibility of the left
ventricle (which is a passive property).
Aurigemma GP, Gaasch WH. Clinical practice. Diastolic heart failure. N Engl J Med 2004; 351:1097
PATHOPHYSIOLOGY
The net effect of Abnormal LV diastolic
relaxation and distensibility is a relative shift of
LV filling from early to the latter part of diastole.
2.Aurigemma GP, Gaasch WH. Clinical practice. Diastolic heart failure. N Engl J Med 2004; 351:1097.
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Pathways to Heart Failure in the Cardiovascular Continuum
Myocardial
infarction
Coronary
thrombosis
Arrhythmias
Myocardial
ischemia
Stroke
CAD
Sudden
death
Remodeling
Renal
disease
"Concentric“
Dilation of
ventricles
Heart failure
Arteriosclerosis LVH
Risk-factors
(smoking, diabetes,
cholesterol, hypertension)
"Eccentric
(dilated)
Form"
End-stage
heart disease
CLINICAL MANIFESTATIONS
The clinical manifestations of diastolic
heart failure (DHF) are identical to those of
systolic HF (SHF).
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IMPAIRED RESPONSE TO STRESS
 They tolerate atrial fibrillation poorly.
 They do not tolerate tachycardia well.
 Elevations in systemic blood pressure.
 The acute induction or worsening of diastolic
dysfunction by ischemia
Diagnosis
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Diagnosis
Treatment
Limited evidence.
Use of same drugs as for systolic CHF justified
due to co-morbid conditions
(Atrial fibrillation, hypertension, diabetes mellitus, and
coronary artery disease)
Management of these patients is based on the
control of physiological factors
(blood pressure, heart rate, blood volume, and
myocardial ischemia)
Hunt, et al. 2009 ACCF/AHA Heart Failure Guidelines. (Circulation. 2009;119:e391-e479.
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Completed trials for HF with
preserved EF
Lam CSP. Ann Acad Med. 2009;38(8): 663-666.
Hong Kong trial
ACE vs. ARB vs. diuretics
Yip GWK, et al. Heart 2008;94;573-580.
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OPTIMIZE – HF: Betablockers
Organized Program to Initiate Lifesaving Treatment in
Hospitalized Patients With Heart Failure
Hernandez, et al. JACC. 2009 Jan 13;53(2):184-92
SENIORS: Nevibolol
Study of the Effects of Nebivolol Intervention on Outcomes
and Hospitalization in Seniors with Heart Failure)
Ghio S, et al. Eur Heart J. 2006;27: 562–568
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How do patients with HFpEF die?
 Annual mortality ranging from 10% to 30%
 Cardiovascular deaths are 51–60% in
epidemiological studies and 70% in clinical trials.
 Sudden death and HF death are the leading
cardiac modes of death, though their
proportions are lower than in HFrEF.
Chan MMY, Lam SP Eur J Heart Fail 2013; 15: 604
How do patients with HFpEF die?
 Non-cardiovascular deaths constitute a higher
proportion of deaths in HFpEF than in HFrEF
(fewer coronary heart deaths).
 Key mortality risk factors include age, gender,
body mass index, burden of co-morbidities, and
coronary artery disease.
Chan MMY, Lam SP Eur J Heart Fail 2013; 15: 604
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2012 ESC Guidelines on
Pharmacological treatment of HFpEF
 “No treatment has yet been shown,
convincingly, to reduce morbidity and mortality
in these patients”.
 Diuretics are used to control sodium and water
retention and relieve breathlessness and edema.
2012 ESC Guidelines on
Pharmacological treatment of HFpEF
 Adequate treatment of hypertension and
myocardial ischemia with BB is important, as is
control of HR if AF.
 Drugs that should be avoided in HFrEF should also
be avoided in HFpEF, with the exception of CCBs.
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2013 ACC/AHA HF Guidelines
Treatment of HFpEF
 Control Hypertension (I B)
 Diuretics if needed (I C)
 Beta-blockers, ACE-I in hypertensive
(reasonable, IIa C)
 ARBs in HFpEF (may be considered, II b B)
 Revascularization (reasonable, IIa C)
 Management of A Fib (reasonable, IIa C)
Summary
 Pathophysiology, etiology, and treatment for
HFpEF are distinct.
 Lack of mortality benefit for medications
treating HFpEF.
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Summary
 Future studies are necessary to determine
optimal therapies.
 Due to lack of strong clinical evidence,
treatment guidelines recommend empiric
medication selection based on symptoms and
co-morbidities.
Thank you
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