HF-PEF: Symptoms, quality of life and mortality/morbidity

Transcription

1 HF-PEF: Symptoms, quality of life and mortality/morbidity May 21, 2011 John McMurray, MD Eugene Braunwald Scholar in Cardiovascular Diseases, Brigham & Women s Hospital Boston; Visiting Professor of Medicine, Harvard Medical School. FINANCIAL DISCLOSURE: None relevant to this presentation CHARM ESC Hotline

2 Presentation Outline Source of data Symptoms and signs Quality of life Clinical outcomes

3 What data to compare HF-PEF with HF-REF? Epidemiologic studies? Clinical trials?

4 What data to compare HF-PEF with HF-REF? Epidemiologic studies? Clinical trials? - DIG - CHARM - I-Preserve

5 DIG-Preserved vs. I-Preserve I-Preserve DIG low LVEF DIG-Preserved LVEF (%)

6 Preserved vs. I-Preserve I-Preserve CHARM low LVEF Preserved LVEF (%)

7 HF-REF vs. HF-PEF trials: baseline characteristics % DIG- Preserved (n=988) DIG- Low EF (n=6800) Preserved (n=3023) Low EF (n=4576) I-Preserve (n=4133) Mean age (yr) yr (%) Women (%) SBP (mmhg)

8 HF-REF vs. HF-PEF trials: heart failure etiology DIG- Preserved (n=988) DIG- Low EF (n=6800) Preserved (n=3023) Low EF (n=4576) I-Preserve (n=4133) % Ischemic Hypertensive

9 HF-REF vs. HF-PEF trials: co-morbidity % DIG- Preserved (n=988) DIG- Low EF (n=6800) Preserved (n=3023) Low EF (n=4576) I-Preserve (n=4133) Hypertension Diabetes Atrial fibrillation

10 Presentation Outline Source of data Symptoms and signs Quality of life Clinical outcomes

11 % CHARM: Baseline signs, symptoms and radiographic findings Alternative Added Preserved 0 Oedema Orthopnoea PND Rest dyspnoea S 3 Crackles JVP >6 cm Cardiomegaly

12 Presentation Outline Source of data Symptoms and signs Quality of life Clinical outcomes

13 Minnesota Living With Heart Failure Questionnaire Most extensively used and validated quality of life instrument in heart failure 21 item questionnaire physical and emotional dimensions; score 0-5 per item (0=none; 5 very much) Possible score (lower score better QoL) Men better QoL than women; older patients better QoL than younger patients

14 QoL in HF: reduced vs preserved EF Distribution (%) Minnesota Living with Heart Failure Summary Score Range HF-Preserved EF HF-Low EF 0-<10 10-<20 20-<30 30-<40 40-<50 50-<60 60-<70 70-<80 80-<90 >90 Better quality of life Worse quality of life Lewis et al. Eur J Heart Failure 2007;9:83-91

15 MLwHF: HF-REF and HF-PEF compared (lower score is better) HF-PEF CHARM preserved EF: median 40 (IQR 20-60) I-PRESERVE: mean MLwHF score 42.4 (SD 20.7) HF-REF CHARM low EF: median 39 (IQR 21-59) CARE-HF: 45.4 (SD 21.2) Val-HeFT : 32.4 (SD 23) ELITE (an elderly low EF population): mean score ~ 24.5 (SD ~20)

16 Presentation Outline Source of data Symptoms and signs Quality of life Clinical outcomes

17 Mortality and morbidity Low EF vs. Preserved CV death CHF hospitalization Proportion of patients (%) Low EF Preserved months Proportion of patients (%) Low EF Preserved months

18 HF-REF vs. HF-PEF: All-cause mortality DIG and CHARM Rate per 1000 patient years DIG-REF (overall) DIG-PEF (overall) CHARM Alternative (placebo) Added (placebo) Preserved (placebo)

19 HF-REF vs. HF-PEF: HF hospitalization DIG and CHARM Rate per 1000 patient years DIG-REF (overall) DIG-PEF (overall) CHARM Alternative (placebo) Added (placebo) Preserved (placebo)

20 HF-REF vs. HF-PEF: All-cause mortality CHARM and I-Preserve Rate per 1000 patient years Alternative (placebo) Added (placebo) Preserved (placebo) I-Preserve

21 HF-REF vs. HF-PEF: HF hospitalization CHARM & I-Preserve Rate per 1000 patient years Alternative (placebo) Added (placebo) Preserved (placebo) I-Preserve

22 Do these patients really have heart failure? Hypertensive, overweight women with swollen ankles Outcomes in HF-PEF compared to other populations.

23 I-PRESERVE patients versus those in other clinical trials What are the outcomes of patients in I-PRESERVE compared to patients in other cardiovascular disease trials?

24 Trial Inclusion n Age Female Systolic BP (year) (%) (mmhg) ACTION angina years proven CHD ACCORD diabetes CV disease/ risk factors ALLHAT hypertension years 1 CHD risk factor ANBP-2 hypertension years LIFE hypertension years LVH VALUE hypertension years CV dis./risk fact. HYVET hypertension years I-PRESERVE HF-PEF years HF-PEF Preserved

25 All-cause mortality Rate per 1000 patient years

26 All-cause mortality Rate per 1000 patient years

27 Heart failure hospitalization rates Rate per 1000 patient years * fatal or non-fatal HF

28 Programme: cause of death by LVEF Annualized Incidence (%) n = 1560 n = 1530 n = 1489 n = 1520 Non CV death Sudden Death HF Death Fatal MI Stroke Other CV Death n = 1500 Proportion of deaths non-cv 0 EF <25% EF 26-33% EF 34-40% EF 41-52% EF >53% Ejection Fraction 15% 18% 20% 21% 37% Solomon et al Circ 2005

29 Rates of hospital admission for any cause, all cardiovascular reasons, heart failure only and non-cardiovascular reasons* Alternative Admissions/patient/yr Preserved Admissions/patient/yr All CV HF Non-CV 0 All CV HF Non-CV *Placebo group

30 Summary and conclusions Compared with HR-REF, patients with HF-PEF are older and more frequently female, overweight and hypertensive. However, contrary to popular belief, certain co-morbidities such as diabetes, anemia and AF are similar (others are not e.g. COPD). Symptoms, quality of life and common laboratory measurements are similar (although neurohumoral activation less marked in HF-PEF than in HF-REF). Mortality and morbidity rates lower in HF-PEF The relative proportion of both fatal and non-fatal non-cv events is greater in HF-PEF (compared with HF-REF).