HFNEF Bijoy K. Khandheria, MD. FASE, FACP, FACC FESC Professor of Medicine University of Wisconsin Director. Echocardiography Services Aurora Health Care No conflicts or off label use CP1173868-1 Heart Failure is A complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with (diastolic) or eject blood (systolic) ESC guidelines for heart failure European Heart Journal 25 CP121291-3 Emergence of New Epidemics of Cardiovascular Disease Two new epidemics of cardiovascular disease are emerging: Heart failure and atrial fibrillation. Hospital admissions for heart failure have climbed steadily, so that this condition has become the single most frequent cause of hospitalization in persons 65 years of age and older. CP1173868-7 1 Prevalence of CHF by Age NHANES II and III % 8 6 4 1988-91 1976-8 2 3 35 4 45 5 55 6 65 7 75 8 Age (years) CP1173868-71
CP121291-8 Symptoms: Rest or exercise Systolic dysfunction Heart failure Structural abnormality Diastolic dysfunction High filling pressure The Burden of Systolic and Diastolic Ventricular Dysfunction in the Community Appreciating the Scope of the Heart Failure Epidemic JAMA, 23 Margaret M. Redfield, MD Steven J. Jacobsen, MD, PhD John C. Burnett, Jr., MD Douglas W. Mahoney, MS Kent R. Bailey, PhD Richard J. Rodeheffer, MD CP1173868-84 In the community, systolic dysfunction is frequently present in individuals without recognized CHF. Furthermore, diastolic dysfunction as rigorously defined by comprehensive Doppler techniques is common, often not accompanied by recognized CHF, and associated with marked increases in all-cause mortality. CP1173868-85 DHF in Population-Based Studies 5% DHF SHF Olmsted Co, MN 43% 57% Circulation, 1998 Framingham Study 51% 49% JACC, 1999 CV Health Study 55% 45% AJC, 21 Strongheart Study 53% 47% AJC, 2 CP1173868-87
Diastolic Heart Failure What We Know CP1173868-5 Diastolic Heart Failure 4-5% with CHF nl syst function Hospital readmission rates similar to SHF DHF is associated with better prognosis Therapeutic approach may be different Optimal Rx not defined CP1173868-6 1..8.6 Survival.4.2 Expected EF 5% EF <5% P=.279 1 2 4 5 6 Senni: Circ, 1998 Years CP1173868-7 Diastolic Heart Failure Systemic hypertension Systemic hypertension Systemic hypertension Left ventricular hypertrophy Ischemic heart disease Diabetic heart disease Valvular heart disease
Diastolic Heart Failure Restrictive cardiomyopathy Constrictive pericarditis Hypertrophic cardiomyopathy Infiltrative disorders Storage disorders Obstructive sleep apnea Obesity and female gender How to Establish Diagnosis of Diastolic Heart Failure Presence of signs and symptoms of heart failure Presence of normal or only mildly abnormal systolic function Evidence of abnormal LV relaxation, filling, or stiffness CP1173868-9 European Heart Journal 19:99-13, 1998 CP1173868-1 Defining Diastolic Heart Failure A Call for Standardized Diagnostic Criteria Ramachandran S. Vasan, MD Daniel Levy, MD Circulation, 2 CP1173868-11
Diastolic Function Parameters in the Management of Heart Failure ACC/AHA Guidelines-HF Management...diagnostic evaluation should... Determine the type (and severity) of cardiac dysfunction Determine prognosis Guide treatment Doppler echocardiography is of particular benefit to assess systolic and diastolic function CP1173868-2 Diastology 24 Doppler Evaluation Mitral inflow velocities Pulmonary venous flow Flow durations, isovolumic times LA volume, LA size Flow propagation (color MM) Doppler tissue imaging Volume loading/unloading Respiratory variations Exercise Diastolic Dysfunction Essentials Mitral, pul vein Normal diastolic Mild Pseudo Restrictive function I II III-IV DT 25-15 ms >25 ms 25-15 ms <15 ms a-duration MV > PV MV PV PV > MV PV > MV Maneuver Annular TDI Valsalva E (m/s).1-.15 >.1 >.7 >.5 LA volume <28 cc/m 2 >28 cc/m 2 >34cc/m 2 Large CP1137253-23 Diastolic Function and Determine the Type and Severity of Cardiac Dysfunction Case 1 Asymptomatic 75-year-old male with LBBB EF 2% CP1173868-27
A E CP1173868-28 Diastolic Function and Determine the Type and Severity of Cardiac Dysfunction Case 1 Asymptomatic 75-year-old male with LBBB EF 2% Grade I diastolic dysfunction CP1173868-29 Diastolic Function and Determine the Type and Severity of Cardiac Dysfunction Case 2 68-year-old male with class IV CHF symptoms EF 45-5% CP1173868-3 E A CP1173868-31
S D CP1173868-32 E A CP1173868-33 Diastolic Function and Determine the Type and Severity of Cardiac Dysfunction Case 2 68-year-old male with class IV CHF symptoms EF 45-5% Mild systolic dysfunction Severe (grade III-IV) diastolic dysfunction CP1173868-34 Diastolic Function Parameters in the Management of Systolic Heart Failure Assess Prognosis CP1173868-35
Diastolic Function and Assess Prognosis Survival Free from Urgent Transplantation % 1 8 6 4 Log-rank P=.1 Stable nonrestrictive Reversible restrictive Unstable nonrestrictive Irreversible restrictive 2 6 12 18 24 3 36 Pozzoli et al: Circ, 1997 Months CP1173868-36 Diastolic Function Parameters in the Management of Systolic Heart Failure Guide Therapy CP1173868-45 Diastolic Function and Medical Therapy Guide Probability of survival (%) 1 8 6 4 Init PAW 16 Init PAW 31±7 final PAW 16 Stevenson LW: AJC, 199 2 P=.1 Init PAW 31±7 final PAW >16 2 5 7 1 12 Months on tailored therapy CP1173868-47 1 Effect of Oral Therapy on Diastolic Function Parameters Free Cardiac Death 86% Free Death, Tx, CHF Hospitalization 8 P<.5 6 52% % 4 Prolonged DT (>125 ms) 2 Persistent short DT ( 125 ms) 12 24 36 48 Months Temporelli et al: JACC, 1998 64% P<.1 14% 12 24 36 48 Months CP1173868-48
Diastolic Function and Medical Therapy Guide CP1173868-51 4 The Natural History of Diastolic Function and LV Filling Normal Abnormal relaxation Pseudonormalization (reversible) Restriction Restriction (irreversible) Mean LAP N- TAU NYHA I-II II-III III-IV IV Grade I II III IV CP1173868-52 Management of Patient with CHF Assess Prognosis Case 1 Asymptomatic 75-year-old male with LBBB EF 2% Mitral inflow E/A=.33, D=29 ms Leg lifting no change in E/A Stable nonrestrictive good prognosis CP1173868-53 Diastolic Function and Medical Therapy Guide No need to increase diuretic use Maintain AV synchrony Avoid tachycardia Focus on maximal neurohumoral antagonism (BB and ACEi) Best prognosis CP1173868-54
Diastolic Function and Medical Therapy Guide DT 11 ms CP1173868-57 4 The Natural History of Diastolic Function and LV Filling Normal Abnormal relaxation Pseudonormalization (reversible) Restriction Restriction (irreversible) Mean LAP N- TAU NYHA I-II II-III III-IV IV Grade I II III IV CP1173868-58 Diastolic Function and Medical Therapy Guide Increase diuretic therapy Maximize neurohumoral anatagonism Consider adjunctive therapy Reassess frequently Consider transplantation Prognosis guarded DT 11 ms CP1173868-59 Diastolic Function and Assess Prognosis Case 2 68-year-old male with class IV CHF symptoms EF 45% E/A=4, DT=146 ms Irreversible restrictive poor prognosis CP1173868-6
Ancillary Treatment of CHF Associated with Systolic Dysfunction Additional vasodilators Spironolactone (class III-IV) Inotropic therapy (class IV) Antiarrhythmics Devices Surgical (CABG/valve/transplant) CP1173868-67 CHARM Equivocal results PEP-CHF I-PRESERVE DHF clinical trials SWEDIC SENIORS Hong Kong