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12/4/2013
Diastolic Heart Failure Is A Cardiac Problem‐Debate
Hanan B. ALBackr , MBBS,FRCPC
Assistant professor of Medicine
Cardiology consultant , echocardiography
King Fahad Cardiac Center, KKUH
College of Medicine, King Saud University,
Riyadh
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CASE
62 yo F with HTN & AFIB
Previous NYHA I with normal systolic function
Now progressive dyspnea with exertion
ER: AFIB at 120 bpm, Pulm Edema
Case scenario A 68-year-old female has exertional breathlessness, ankle swelling
and a cough.
2 days H/O fever
Past medical history: She has type 2 diabetes but no previous cardiac
history .
On examination
You find ankle oedema, and 2 cm hepatomegaly
Hypertension, BP=190/95
On chest examination: Bilateral basal crackels
You suspect heart failure
±
bronchopneumonia
The BNP level is 300 pg/ml, what would you do next?
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Answer:
You would refer the patient to have
specialist assessment and
echocardiography
The echocardiogram shows no evidence
of left ventricular systolic dysfunction,
Echocardiogram
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• So the cardiology specialist suggests that the patient has heart failure with preserved ejection fraction?? or Diastolic heart failure???
• The specialist advises the introduction of a diuretic. • Start ACE inhibitor therapy at a low dose and titrate upwards at short intervals (for example, every 2 weeks) until the optimal tolerated or target dose is achieved.
Circulation September 20, 2005
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DHF OR What is it? How common?
Dignosis!!
How serious?
How to treat it!
ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult
Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.
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Circulation September 20, 2005
2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of adults with heart failure Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.
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The 2010 Heart Failure Society of America Comprehensive Heart Failure Practice Guideline
• HF is a syndrome caused by cardiac dysfunction, generally resulting from myocardial muscle dysfunction or loss and characterized by either LV dilation or hypertrophy or both. Whether the
dysfunction is primarily systolic or diastolic
or mixed, it leads to neurohormonal and circulatory abnormalities, usually resulting in characteristic symptoms such as fluid retention, shortness of breath, and fatigue, especially on exertion.
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, Heart Rhythm Society, and International Society for Heart and Lung Transplantation
Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation
© American College of Cardiology Foundation and American Heart Association, Inc.
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Definition of Heart Failure
Classification
Ejection
Fraction
Description
I. Heart Failure with
Reduced Ejection Fraction
(HFrEF)
≤40%
Also referred to as systolic HF. Randomized clinical trials have
mainly enrolled patients with HFrEF and it is only in these patients
that efficacious therapies have been demonstrated to date.
II. Heart Failure with
Preserved Ejection
Fraction (HFpEF)
≥50%
Also referred to as diastolic HF. Several different criteria have been
used to further define HFpEF. The diagnosis of HFpEF is
challenging because it is largely one of excluding other potential
noncardiac causes of symptoms suggestive of HF. To date,
efficacious therapies have not been identified.
a. HFpEF, Borderline
41% to 49%
These patients fall into a borderline or intermediate group. Their
characteristics, treatment patterns, and outcomes appear similar to
those of patient with HFpEF.
b. HFpEF, Improved
>40%
It has been recognized that a subset of patients with HFpEF
previously had HFrEF. These patients with improvement or recovery
in EF may be clinically distinct from those with persistently
preserved or reduced EF. Further research is needed to better
characterize these patients.
Treatment of Stages A to D
Treatment for Stage C HFpEF
JACC Vol. 62, No. 16, 2013 Yancy et al. October 15, 2013:e147–239
2013 ACCF/AHA Heart Failure Guideline
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Treatment of HFpEF
Recommendations
Systolic and diastolic blood pressure should be controlled
according to published clinical practice guidelines
Diuretics should be used for relief of symptoms due to
volume overload
Coronary revascularization for patients with CAD in
whom angina or demonstrable myocardial ischemia is
present despite GDMT
Management of AF according to published clinical
practice guidelines for HFpEF to improve symptomatic
HF
Use of beta-blocking agents, ACE inhibitors, and ARBs
for hypertension in HFpEF
ARBs might be considered to decrease hospitalizations in
HFpEF
Nutritional supplementation is not recommended in
HFpEF
COR
LOE
I
B
I
C
IIa
C
IIa
C
IIa
C
IIb
B
III: No
Benefit
C
JACC Vol. 62, No. 16, 2013 Yancy et al. October 15, 2013:e147–239
2013 ACCF/AHA Heart Failure Guideline
Prevalence of diastolic dysfunction unknown, as asymptomatic disease most common
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500,000 new people with heart failure each year
• 1/3 diastolic heart failure
• 1/3 systolic heart failure
• 1/3 mixture
Frequency of heart failure with normal systolic function
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Progression of Left Ventricular Diastolic Dysfunction and Risk of Heart Failure
JAMA. 2011;306(8):856‐863
Objective To measure changes in diastolic function over time and to determine the relationship between diastolic dysfunction and the risk of subsequent heart failure.
Main Outcome Measures—Incident heart failure
From: Progression of Left Ventricular Diastolic Dysfunction and Risk of Heart Failure
JAMA. 2011;306(8):856-863. doi:10.1001/jama.2011.1201
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From: Progression of Left Ventricular Diastolic Dysfunction and Risk of Heart Failure
JAMA. 2011;306(8):856-863. doi:10.1001/jama.2011.1201
Results
• Over 4 ± 0.3 years diastolic dysfunction prevalence increased from 23.8% to 39.2% (P <0.001). • Diastolic function grade worsened in 23.4%
of participants, was unchanged in 67.8% , and improved in 8.8%. Worsened diastolic dysfunction was associated with age ≥65 years.
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Results
• During 6.3 ± 2.3 years of additional follow‐up, heart failureoccurred in 2.6% ,7.8% and 12.2% of persons whose diastolic function normalized or remained normal, remained or progressed to milddysfunction, or remained or progressed to moderate‐severe dysfunction, respectively. (P <0.001)
• Diastolic dysfunction was associated with incident heart failure after adjustment for age, hypertension, diabetes, and coronary disease .
Conclusions
‐ In a population‐based cohort undergoing 4 years of follow‐up, prevalence of diastolic dysfunction increased.
‐ Diastolic dysfunction was associated with development of heart failure during 6 years of subsequent follow‐up.
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Owan T et al. N Engl J Med 2006;355:251-259
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Heart Failure with Preserved Ejection Fraction.
Owan T et al. N Engl J Med 2006;355:251-259
Secular Trends in the Prevalence of Heart Failure
with preseved EFPreserved Ejection Fraction
Owan T et al. N Engl J Med 2006;355:251-259
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Kaplan-Meier Survival Curves for Patients with Heart Failure
and Preserved or Reduced Ejection Fraction
Owan T et al. N Engl J Med 2006;355:251-259
Diastolic Heart Failure ‐ Diagnosis
• No consensus on diagnostic criteria
• Vasan etal. Circulation 2000;101:2118
• “Definite vs Probable Diastolic CHF”
1. Clinical evidence of raised LVEDP
2. “Normal” LV systolic function (EF > 50%)
3. Objective evidence of diastolic dysfunction
Elevated LVEDP on cardiac catheterization E:A reversal with prolonged Decel’n Time (>240)
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Diagnostic Criteria: HF with Reduced Versus HF with Preserved EF.
Journal of Cardiac Failure Vol. 16 No. 6 2010
Heart Failure with Preserved Ejection Fraction
• A substantial number of patients with heart failure (HF) have preserved left ventricular ejection fraction (LVEF), variably defined as an LVEF ≥ 40%, ≥45%, or ≥ 50%.
• When these patients have invasive or non‐invasive evidence of abnormal diastolic function (either abnormal relaxation, filling or stiffness) they are said to have ‘‘diastolic HF’
Gaasch WH. Diagnosis and treatment of heart failure based on left ventricularsystolic or diastolic dysfunction. JAMA 1994;271:1276e80.
Smith GL, Masoudi FA, Vaccarino V, Radford MJ, Krumholz HM.Outcomes in heart failure patients with preserved ejection fraction:mortality, readmission, and functional decline. J Am Coll Cardiol 2003;41:1510e8.
4Konstam MA. "Systolic and diastolic dysfunction" in heart failure? Time for a new paradigm. J Card Fail 2003;9:1e3.
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2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
• The definition of HF has now expanded to:
a. HF with reduced ejection fraction (HFrEF, EF ≤40%)
b. HF failure with preserved ejection fraction (HFpEF, EF ≥50%)
c. HFpEF, borderline (EF 41‐49%)
d. HFpEF, improved (EF >40%)
• Aim for control of systolic and diastolic blood pressures, as well as volume status, to treat HFpEF.
Sequence of Mechanical Events in Diastole
Notomi, Y. et al. J Am Coll Cardiol Img 2009;2:717‐719
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Mechanism of LV Twist
Bertini, M. et al. J Am Coll Cardiol Img 2009;2:1425‐1435
Left ventricular rotation (LVrot) at apical and basal levels during systole by "overlaid" speckle tracking images
Notomi, Y. et al. J Am Coll Cardiol 2005;45:2034‐2041
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Diastolic Heart Failure ‐ Prognosis
• Annual mortality 5‐8% for diastolic HF vs 10‐
15% with systolic HF; however morbidity rates the same
• Prevalence and mortality increased with age
• Peak MVO2 most accurate predictor of prognosis
Mortality and Morbidity.
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From: Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: Prevalence and mortality in a population‐based cohort
J Am Coll Cardiol. 1999;33(7):1948‐1955. doi:10.1016/S0735‐1097(99)00118‐7
Figure Legend:
The distribution of left ventricular ejection fraction (LVEF) values among men and women with congestive heart failure is displayed in the figure. Twenty‐seven of 40 men (67.5%) had a reduced LVEF (<0.50), compared with only nine of 33 women (27%).
Date of download: 11/11/2013
Copyright © The American College of Cardiology. All rights reserved.
From: Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: Prevalence and mortality in a population‐based cohort
J Am Coll Cardiol. 1999;33(7):1948‐1955. doi:10.1016/S0735‐1097(99)00118‐7
Figure Legend:
Kaplan‐Meier survival plots of CHF patients with normal and reduced LVEF are displayed. The overall survival of CHF subjects with reduced LVEF is worse than that of CHF subjects who have a normal LVEF. This comparison does not account for gender differences in the composition of the two groups. Abbreviations as in Figure 2.
Date of download: 11/11/2013
Copyright © The American College of Cardiology. All rights reserved.
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Results
CHF cases (51%) had a normal LVEF; 36 (49%) had a reduced LVEF. • During a median follow‐up of 6.2 years, CHF cases with normal LVEF experienced an annual mortality of 8.7% versus 3.0% for matched control subjects • Congestive heart failure cases with reduced LVEF had an annual mortality of 18.9% versus 4.1% for matched control subjects
Conclusion
‐Normal LV systolic function is often found in persons with CHF in the community and is more common in women than in men. ‐Although CHF cases with normal LVEF have a lower mortality risk than cases with reduced LVEF, they have a fourfold mortality risk compared with control subjects who are free of CHF.
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Could diastolic parameters be important for prognosis?
Take home message
• left ventricular diastolic dysfunction is highly prevalent, tends to worsen over time, and isassociated with advancing age.
• Worsening diastolic function can be detected even in apparently healthy persons. • The persistence or progression of diastolic dysfunction is an independent risk factor for heart failure in the elderly.
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