Objectives. Let s start at the beginning 10/28/2014. What is Heart Failure? Understanding Heart Failure with Preserved LV Systolic Function

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1 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. 1

2 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. 2

3 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 highoutput states (eg. Anemia, thyrotoxicosis) Right Ventricular Failure 3

4 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 4

5 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 5

6 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 6

7 Normal Diastolic Function 7

8 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. 8

9 Diastolic HF: Epidemiology Prevalence of DHF increases with age: Of those with DHF: 15% are < 50 years old 33% are % 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 Sep 23, cited in RW 9

10 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 10

11 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 11

12 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. 12

13 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 13

14 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 14

15 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 15