10/28/2014

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Understanding Heart Failure with Preserved LV Systolic

Function

Eric Ernst, MD

Medical Director

C.O.R.E. Clinic

Objectives

• Clarify the terminology surrounding right heart failure and diastolic heart failure

• Understand the physiology of heart failure

• Differentiate RHF and DHF from other HF states

• Identify some common cardiac abnormalities associated with RHF and DHF

• Explore treatment options

Let’s start at the beginning

What is Heart Failure?

Heart Failure is a syndrome caused by elevated pressures within a vascular system…

…resulting in impaired oxygen transfer or extravasation of fluid into tissues.

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Diagram of Circulation

What is Heart Failure?

“Left HF”: syndrome of symptoms and signs caused by elevated pressure in the pulmonary capillary bed.

“Right HF”: syndrome of signs and symptoms caused by elevated central venous pressure.

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The “Spaces” of the body

• “First” space: intravascular fluid

• “Second” space: interstitial fluid

Must allow diffusion of CO2 and O2

• “Third” space: potential spaces; eg.

pleural, peritoneal, pericardial spaces. Also intestinal in some cases.

Right Heart Failure

• Edema, ascites, pleural effusion

• Causes: Pulmonary arterial HTN; esp. OSA, obesity, LHF, lung disease (cor pulmonale), mitral valve disease (MS/MR). Less commonly PPH, autoimmune disease, chronic thromboembolic disease, etc.

• Need to exclude pericardial disease and high-output states (eg. Anemia, thyrotoxicosis)

Right Ventricular Failure

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Treatment of RHF

• Treatment of pulmonary HTN: vasodilators, CPAP, O2

• Treatment of LHF

• Mitral valve surgery

• Lymphedema clinic, compression stockings

• Diuretics

Colors of Salt

• White

• Black

• Red

• Yellow

• Green

• Brown

• Clear

• Table salt

• Soy sauce

• Catsup

• Mustard

• Pickles

• Soups & gravies

• Saline

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Left Heart Failure

• Dyspnea, fatigue, edema

• Causes: Impaired LV contractility

And

Impaired LV filling (diastolic dysfunction)

Diastolic dysfunction vs. Diastolic HF

Diastolic dysfunction refers to abnormal relaxation or distensibility of the LV resulting in impaired filling regardless of EF or symptoms

Diastolic HF refers to the syndrome of HF occurring in a pt with diastolic dysfunction, also called HFpEF

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What is diastolic heart failure?

1. Signs and symptoms of HF

2. Preserved EF ( > 40%)

3. Evidence of abnormal diastolic LV filling pattern by echo

4. Elevated BNP

Often a challenging diagnosis.

LV Filling Pressures

Overview of Diastolic Function

• Isovolumic relaxation: energy dependent

• Rapid pressure decline: “untwisting” and elastic recoil of LV produces suction

• LV becomes compliant and distensible

• Atrial contraction contributes an additional 20-30% to LV filling with an increase of less than 5mmHg pressure

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Normal Diastolic Function

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High Compliance

Increased Stiffness

Diastolic HF: Epidemiology

• 50% of pts with HTN have DD (most are Asx)

– 11-15% over 65 will develop HF in 5 years.

• DHF comprises 40-60% of pts with HF: Higher than previously thought and rising.

• Rising rate due to aging of the population and increasing prevalence of risk factors: HTN, diabetes, obesity, anemia, atrial fibrillation.

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Diastolic HF: Epidemiology

• Prevalence of DHF increases with age:

– Of those with DHF:

15% are < 50 years old

33% are 50-70

50% are > 70

Diastolic HF: Epidemiology

Of 19,000 hospital discharges for HF:

35% had normal EF

79% with normal EF were women

51% with decreased EF were women

• Mortality rate is similar to systolic HF:

– 1 year, all-cause mortality 22-29%

Bhella et al., JACC. 2014 Sep 23,

cited in RW

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LV distensibility was greater in committed (21%) and competitive (36%) exercisers than in sedentary subjects

Diastolic HF: Causes

• LVH with chronic HTN

• Valvular heart disease, especially AS

• HCM

• CAD

• Restrictive CM

• Worsened by afib, anemia, malnutrition, renal failure

LVH as a cause of DHF

1. Increased passive stiffness

Increased concentric mass

Interstitial fibrosis

2. Limited coronary vascular reserve

Subendocardial ischemia, esp. combined with DM

Perivascular fibrosis

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Ischemic Cascade

Impaired ATPase in sarc.

reticulum results in decreased

clearance of cytosolic Ca++

Restrictive CM

Cardiomyopathic disease characterized by:

• Nondilated LV chamber

• Wall thickness may be increased or normal

• Rigid, noncompliant walls

• Restrictive filling = high filling pressures

• Normal EF

Restrictive CM

Infiltrative:

Amyloid, Sarcoid

Non-infiltrative:

HCM, Scleroderma

Storage diseases:

Hemachromatosis, Gaucher/Fabry’s Disease

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Restrictive CM (cont.)

Endomyocardial

Hypereosinophilic syndrome

Carcinoid heart disease

Metastatic cancer

Radiation

Anthracycline chemotherapy

Drugs such as ergotamine, methysergide

Case Presentation

81 year old woman admitted with dyspnea, 3am

• Hypertensive urgency, BP 220/110

• Sinus tachycardia, HR 120’s

• ST depression

• Troponin 2.3

• BNP 20,000

• Echo: LVH, EF 65%, LVOT obst., Restrictive filling

Case Presentation

3 vessel CAD by cath (severe pLAD) = CABG

She returned 3 weeks post CAB with CHF, HTN urgency

Meds increased.

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Case Presentation

She returned 3 weeks later with CHF, HTN urgency again.

Overnight oximetry = abnormal.

Severe OSA by sleep study.

No more admissions for HF in 4 years.

Treatment Goals for DHF

1. Reduce the consequences of diastolic dysfunction

2. Reduce the factors responsible for diastolic dysfunction

Analogous to treatment of systolic HF

Treatment Goals for DHF

• Revascularization, if necessary

• Afib: Rhythm control vs. Rate control

• Address valvular heart disease

• Consider pericardial disease

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Reduce Venous and Pulmonary Congestion

• Sodium restriction

• Diuretics

Volume sensitive! Be careful to balance relief of symptoms with complications of diuretics, such as hypotension and azotemia

Control of Heart Rate

• Calcium channel blockers, Beta blockers

Increase filling time, improve relaxation?

• Observational data supporting verapamil

• SENIORS Trial:2128 pts with HF over 70 yrs

752 with HFpEF (EF over 35%)

Nebivolol (Bystolic) vs. standard therapy

Reduced mortality/hosp admit 31.1% vs. 35.3%

Optimal HTN Management

• ACE-I/ARB’s?

Improves LV loading conditions in the short term

Favors regression of LVH in the long term

• Not well proven

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Treatment of DHF

CHARM Preserved

3024 patients with HF, EF > 40%

Candesartan vs. standard therapy

No improvement in cardiac death or HF hosp.

Many did not have diastolic dysfunction

Treatment of DHF

Hong Kong DHF Trial

450 patients with DHF

Diuretics vs. irbesartan/diuretic vs. ramipril/diuretic

No difference in QOL, 6 min walk, or diast dys

Valsartan did not improve diastolic dysfunction after 9 months vs. placebo

Conclusion

• Diastolic Heart Failure is nearly as common as systolic heart failure

• Diastolic Heart Failure is often difficult to diagnose

• Treatment data is lacking

• Best treatment is based on relief of symptoms with diuretics and optimal BP control using beta blockers or CCB’s