Diastolic Heart Failure. Edwin Tulloch-Reid MBBS FACC Consultant Cardiologist Heart Institute of the Caribbean December 2012

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1 Diastolic Heart Failure Edwin Tulloch-Reid MBBS FACC Consultant Cardiologist Heart Institute of the Caribbean December 2012

2 Disclosures Have spoken for Merck, Sharpe and Dohme Sat on a physician advisory panel for Sanofi-Aventis

3 What is Heart Failure? Heart failure is the pathophysiologic state in which the heart via an abnormality of cardiac function fails to pump blood at a rate commensurate with the needs of metabolizing tissue and/ or does so at elevated ( diastolic) filling pressure

4 Congestive Heart Failureredefined A clinical syndrome caused by an abnormality of the heart and recognised by a characteristic pattern of haemodynamic, renal, neural and hormonal responses (Philip Poole Wilson, 1985) A syndrome in which cardiac dysfunction is associated with reduced exercise tolerance, a high incidence of ventricular arrhythmias and shortened life expectancy (Jay Cohn, 1988)

5 Heart failure-a major public health problem US STATS- staggering! >1 million hospitalizations per year 5.7 million people living with heart failure >500,000 new cases per year annual cost >60 Billion per year 44% of these patients have preserved systolic function Jamaica : number one reason for readmission at the Kingston Public Hospital

6 Diastolic Heart Failure Lessons relearned from the Irish School of Cardiology Patients may be minimally symptomatic between acute exacerbations Even when asymptomatic they have abnormal diastolic function Progressive decline and shortened life expectancy even when exacerbations are appropriately treated.

7 Diastolic Heart Failure From an abnormal haemodynamics view point to Neurohormonal derangements implicating cardiovascular, autonomic, renal and endocrine systems Apoptotic myocyte death from increased myocyte energy expenditure

8 Diastolic Heart Failure Types of Heart Failure Systolic heart failure Heart Failure with preserved systolic function-includes high output heart failure, heart failure from right sided heart disease and of course diastolic heart failure

9 Diastolic Heart Failure What mechanisms underlie diastolic heart failure? Abnormalities of myocardial relaxation-calcium removal from the SR and myocyte crossbridge detachment Increased myocardial stiffness -myocyte hypertrophy, modification of collagen and interstitial fibrosis increased end diastolic and left atrial pressure

10 Heart Failure

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12 Where does it all begin? Myocardial injury: acute ( myocardial infarction, myocarditis) or chronic ( volume pressure overload like obesity and hypertension or valvular heart disease,chronic ischaemia, persistent inflammation from immune activation )

13 Diastolic Heart Failure Systole Diastole

14 Starlings Curve Frank-Starling curves in CHF

15 Afterload and Heart Failure Effect of increasing afterload on cardiac function

16 Diastolic Heart Failure

17 Diastolic Heart Failure Patient characteristics older History of hypertension and left ventricular hypertrophy Diabetic Obese Female Chronic Kidney Disease Obstructive sleep apnoea

18 Symptoms of (advanced)heart failure Shortness of breath on exertion which progresses Orthopnoea / Paroxysmal Nocturnal dyspnoea Swelling of the abdomen ( ascites) and extremities Fatigue Confusion, memory impairment Sleep disturbance

19 Diastolic Heart Failure Lessons relearned from the Irish School of Cardiology Patients may be minimally symptomatic between acute exacerbations Even when asymptomatic they have abnormal diastolic function Progressive decline and shortened life expectancy even when exacerbations are appropriately treated.

20 Signs of Heart failure Right sided signs: jugular venous distension, hepatomegaly, ascites, leg swelling and pleural effusion Left sided signs : gallop rhythm and pulmonary rales

21 Diastolic Heart Failure Signs and symptoms of CHF LVEF> 50% Invasive or non-invasive evidence of CHF Abnormal diastolic function parameters

22 Diagnosis of Heart Failure Early detection is crucial to treatment Echocardiography ( cardiac ultrasound) allows one to differentiate systolic from diastolic heart failure and to detect Left ventricular hypertrophy and asymptomatic LV dysfunction BNP/Pro-BNP levels allow the early detection of heart failure decompensations

23 Echocardiography

24 Diastolic Heart Failure

25 Echocardiogram

26 Disatolic Heart Failure 4 basic diastolic function parameters Grade 1 ( abnormal relaxation) Grade 2 ( pseudonormalization) Grade 3 ( reversible restrictive filling) Grade 4 ( irreversible restrictive filling)

27 Diastolic Heart Failure

28 Diastolic Heart Failure Lessons relearned from the Irish School of Cardiology Patients may be minimally symptomatic between acute exacerbations Even when asymptomatic they have abnormal diastolic function Progressive decline and shortened life expectancy even when exacerbations are appropriately treated.

29 Do these patients need coronary angiography?

30 Is there a role for Nuclear Cardiology?

31 Diastolic Heart Failure Lessons relearned from the Irish School of Cardiology Patients may be minimally symptomatic between acute exacerbations Even when asymptomatic they have abnormal diastolic function Progressive decline and shortened life expectancy even when exacerbations are appropriately treated.

32 Diastolic Heart Failure Similarities in the pathophysiology of systolic and diastolic heart failuretherapies that work in systolic heart failure should also work in diastolic heart failure Right or wrong?

33 Diastolic Heart Failure Potential neurohormal targets Norepinephrine,epinephrine Renin Angiotensin II Aldosterone Endothelin ANP BNP

34 Diastolic Heart Failure-how do we treat it? Does anything work? Lessons from large trials-no mortality benefits but improvements in functional class and repeat hospitalization (ALLHAT,CHARM-PRESERVED,PEP-CHF, I-PRESERVE,OPTIMIZE- HF and COHERE,TOPCAT) Current treatment focuses in underlying causes eg management of hypertension,rate control in atrial fibrillation,coronary revascularization for ischaemia, slowing heart rate with beta blockers and non-dyhydropyridine calcium entry blockers careful diuresis to relieve pulmonary congestion and peripheral oedema without causing hypotension

35 Diastolic Heart Failure Prognosis Similar All cause mortality to patient with systolic dysfunction High hospital readmission rates Similarly decreased quality of life

36 Typical regimen-cornerstone drugs Diuretics and other preloading reducing agents-use with caution-to avoid underfilling and hypotension ACE and ARBs Digoxin-should not used except for those with atrial fibrillation Beta Adrenergic Blockade ( eg Bisprolol, Metoprolol and Carvdelilol) Adosterone inhibitors( spironolactone, eplerinone)

37 Diastolic Heart Failure Phosphodiesterase-5 inhibitors Statins Exercise conditioning

38 General Meausures Diet- low sodium Promoting weight loss Exercise Programmes Special heart failure clinicsmultidisciplinary with intense surveillance

39 Diastolic Heart Failure Currently no approved device therapies Pacing Therapy Rheos Diastolic Heart Failure Trialbaroreceptor activation device. Cor Assist Device

40 ? Pacing

41 ? Cardiac Resynchronization Therapy

42 Diastolic Heart Failure

43 Ultimate Goal Better clinical outcomes for patients with heart failure, fewer hospitalizations, fewer deaths and better quality of life Reducing the burden of congestive heart failure and the enormous cost of managing patient with the syndrome Preventing heart failure itself-preventing left ventricular dysfunction reducing the population burden of coronary heart disease, untreated hypertension and diabesity-population based approach

44 Diastolic Heart Failure Prevention Reducing the burden of congestive heart failure and reducing the enormous cost of managing patients with congestive heart failure Preventing/treating hypertension and coronary heart disease-primary and primordial prevention

45 Diastolic Heart Failure-Summary Diastolic heart failure is increasingly prevalent as our population ages-it is major public health problem with high morbidity and mortality in symptomatic patients Diagnosis can accurately made noninvasively with echocardiography Treatment is still essentially empiric as there is a paucity of evidence from trial data Treatment of the underlying cause, slowing of heart rate and restoration of sinus rhythm are the key principles to bear in mind

46 Diastolic Heart Failure