heart failure with preserved ef
TRANSCRIPT
Heart Failure with Preserved EF
Dino Recchia, MD, FACC, FHFSA
Diastolic HF 2004 “Diastolic HF” c.2004
Aurigemma G, et al. NEJM 2004
1/3 - 2/3 HFpEF pts do NOT have LVH
1/3 pts in HFpEF trials had normal diastolic function
HFpEF 2018 Biological Phenotypes
HFpEF Prevalence Increasing
44% 31%
15%
13%
41% 56%
1985-1994 2005-2014
EF<40% EF 40-50% EF>50%
Adapted from Ramachandran et al JACC:Cardiovasc Imaging 2017
Chun et al Circ Heart Fail 2012
N = 8543
HFpEF is not Benign
Walter et al Eur Heart J 2014
HFpEF: A Multisystem Disease
Cardiovascular Reserve is Impaired in HFpEF
Impaired Chronotropic
Response
Impaired Peripheral
Vasodilation
Impaired Stroke Volume
Reserve
Borlaug et al Circ Heart Fail 2010
Therapeutic Failures in HFpEF
Class 1 recommendations for HFrEF = 7
Class 1 recommendations for HFpEF = 0
Spironolactone in HFpEF TOPCAT Trial
• International study
• N=3,445
• Symptomatic HFpEF
• EF >45%
• Spironolactone vs placebo
• Endpoint CV death or HF hospitalization
Pitt et al NEJM 2014
Spironolactone in HFpEF
Pfeffer et al Circ 2015
Regional Variation in Outcomes
Regional Variation in Drug Metabolite
Treatment X Benefits A >>> B > C
C
B A
Treatment X has no
overall benefit
Why have HFpEF Treatments Failed?
Guazzi M Circ Heart Fail 2014
Cluster Analysis
Shah et al Circulation 2015
HFpEF Phenotype & Prognosis
Categories of HFpEF
• “Garden-variety” HFpEF (HTN, DM, obesity, CKD)
• CAD-HFpEF
• Right heart failure-HFpEF
• A-fib predominant HFpEF
• HCM-like HFpEF
• High-output HFpEF
• Valvular HFpEF (multiple moderate lesions)
• Rare causes of HFpEF
Hwang et al J Am Coll Cardiol 2014
HFpEF & CAD
• Pts who were discharged with HFpEF and had both an echo and cath within 1 year
• Excluded pts with low EF, ACS, valve disease, HCM, and restrictive CM
• 376 pts eligible
• Results of stress testing, echo, cath reviewed
• Follow up to 10 years
HFpEF an Stress Testing
• 2/3 had CAD • 1/3 of CAD pts had 3V CAD
Hwang et al J Am Coll Cardiol 2014
Hwang et al J Am Coll Cardiol 2014
HFpEF & CAD
Obesity and HFpEF
Ndumele et al J Am Heart Assoc 2016
Risk adjusted for HTN, DM, HLP,
tobacco, physical inactivity
HFpEF Obesity Phenotype
Kitzman et al J Am Coll Cardiol 2016
Diet & Exercise Work Diet and exercise work!
Kitzman D, et al. JAMA 2016
AT = aerobic exercise training, CR = caloric restriction
New Concepts in HFpEF
• Role of the systemic vasculature
• Importance of pulmonary HTN
• “Interventional” therapies for HFpEF
• New options for cardiac amyloidosis
Pulse Wave Velocity & Premature Wave Reflections
• PWV is a measure of aortic stiffness
• Systolic wave reflections occur and are related to PWV
• Ideal PWV ‒ All wave reflections occur during
diastole when aortic valve is closed ‒ Augments coronary perfusion ‒ No change in afterload on the heart
• Increased PWV
‒ Premature wave reflections occur in late systole leading to increased afterload on the heart
Wave Reflections & Exercise Intolerance
Pulmonary HTN & HFpEF
Interatrial Shunt Device for HFpEF
Improving LV Compliance in HFpEF
Hemodynamics of Pericardiotomy
HFSA 22nd Annual Scientific Meeting
Cardiac Amyloidosis: Often Misdiagnosed and Undertreated
Page 2 of 39
HFSA 22nd Annual Scientific Meeting
Cardiac Amyloidosis: Often Misdiagnosed and Undertreated
Page 2 of 39
HFSA 22nd Annual Scientific Meeting
Cardiac Amyloidosis: Often Misdiagnosed and Undertreated
Page 2 of 39
Restrictive Cardiomyopathy
* *
Cardiac Amyloid – wtTTR Variant
• Most common in white males
• Seen at autopsy in 25% HFpEF pts over 85
• Found in 13% of hospitalized pts with HFpEF >60
• 12% pts undergoing TAVR for AS with low gradient
• Bilateral carpal tunnel syndrome and spinal stenosis seen in 50% cases
Cardiac Amyloid – mTTR Variant
• >100 mutations leading to various familial type amyloid syndromes: ‒ Familial amyloid polyneuropathy ‒ Familial amyloid cardiomyopathy
• Val122I mutation most common in US seen in African
Americans with 3-4% heterozygote carriers
• Restrictive CM with minimal neuropathy often misdiagnoses as hypertensive heart disease
Sensitivity 85-90%
Specificity 85-90%
Sensitivity 97% for TTR
Specificity 99% for TTR
Sensitivity 99% Sensitivity 30%
Specificity 75%
Management of Amyloid CM
• Difficult due to narrow window between too high and too low filling pressures
• Torsemide preferred diuretic
• No verapamil or diltiazem
• Avoid digoxin
• Maintain NSR
• New treatment options
New Treatment Option for TT Amyloid CM Tafamadis
• 30% reduction in all cause mortality
• 32% reduction in hospitalizations
• 12-18 months rx re needed before observing the benefit
• Significant improvement in quality of life scores
• Early detection is key
Maurer et al NEJM 2018
Thank You