Heart Failure in Women: More than EF? Dr Goh Ping Ping Cardiologist Asian Heart & Vascular Centre
Overview Review pathophysiology as it relates to diagnosis and management Rational approach to workup: role of echocardiography/cardiac imaging Therapeutic options
Heart Failure: A Clinical Diagnosis Diagnostic features: History Symptoms & signs ECG CXR Natriuretic peptide Differentials: CXR Renal function test, liver function test, full blood count, thyroid function Urinalysis Peak flow or spirometry
Typical Heart Failure Patient
Typical Heart Failure Patient: Reduced LV Systolic Function (HFrEF) The left ventricular ejection fraction is IMPAIRED Mild >35 to 50% Moderate > 25 to 35% Severe <= 25%
LVEF is an Independent Predictor of Mortality Kaplan Meier survival curves stratified by LVEF groups Digitalis Investigation Group (DIG) 7788 stable HF patients Lower EF independently a/w increased mortality after multivariate adjustment Curtis et al. J Am Coll Cardiol, 2003; 42(4):736
Characterise Heart Failure: Reduced vs Preserved EF One-third to half of heart failure hospitalisation due to abnormal diastolic function O Echo at least 2 EF 40-50% O LA enlargement, LV wall thickness 12 mm or O Doppler abnormalities
What is HFpEF? (Heart Failure with Preserved Ejection Fraction) Heart Failure with Preserved Ejection Fraction Heart Failure with Normal Ejection Fraction Diastolic Heart Failure Non-systolic Heart Failure Hypertensive-Metabolic Heart Failure Clinical syndrome of HF Normal/near normal Ejection Fraction Normal/near normal LV dimensions Abnormalities in Relaxation
HFpEF: prognosis HFpEF: prognosis is not benign 30-day re-admission is initially lower than HFrEF Higher BP, higher creatinine Length of stay, 30-day mortality and 1 year mortality as high as HFrEF Comparison of characteristics and outcomes of patients withheart failure preserved ejection fraction versus reduced left ventricular ejection fraction in an urban cohort. Boston University Medical Center Am J Cardiol 2014 Feb 15;113(4):691-6
Primary Diastolic Heart Failure Hypertension Cardiomyopathy - hypertrophic - restrictive - infiltrative Coronary Artery Disease Diabetes Obesity Sleep Apnoea Constrictive Pericarditis
HFPEF: Result of thick and non-compliant heart? Hypertension Concentric LVH Diastolic dysfunction HFPEF
Current Paradigm of HFpEF Diabetes Obesity Ischemia Hypertension HFpEF Renal Dysfunction Deconditioning 31% 27% 26% 16% Normal Concentric remodeling Concentric hypertrophy Eccentric hypertrophy Diastolic Dysfunction Arterial stiffness V-V uncoupling Diminished reserve Chronotropic incompetence Pulmonary hypertension Shah Nat Reserve 2012
Accurate Assessment of Left Ventricular Systolic Function M-mode Biplane Simpson Spectral Tracking automated border detection 3D
Simpson Biplane method of dïscs Total LV volume is calculated from the summation of a stack of discs Less dept on geometric assumptions better endocardial border definition with contrast echocardiography
3-Dimensional LV Volume Measurement Example of three-dimensional (3D) left ventricular (LV) volumes generated by post-processing of a real-time threedimensional echocardiography data set, acquired in a heart failure patient scheduled for cardiac resynchronization therapy. The LV 3D model is subdivided by the software in 17 wedge-shaped (apart from the apex) subvolumes and for each volumetric segment, it is possible to derive time-volume data (lower panel) and assess the time taken to reach the minimum systolic volume (red dots).
Spectral Tracking Echo use 2 D images reflection and scattering of ultrasound in myocardial tissue to produce speckles track unique speckle pattern of myocardial region can assess rotational motion/ torsion alternate method to quantify LV strain and assess systolic and diastolic function
Diastolic dysfunction is Measured by by Doppler Echocardiography Grade 1 Grade 2 Grade 3 normal abnormal pseudonormal restrictive relaxation
Normal or pseudonormal mitral inflow? Mitral Annular Velocity by Tissue Doppler Imaging E/E correlate with LV filling pressure or pulmonary capillary wedge pressure Normal filling pressure - normal E Increase filling pressure - Decrease in E, increase in E
Mitral Inflow Propagation Velocity (Vp) E/Vp 1.5 predicts PCWP > 15 mmhg Normal filling Vp 50 cm/s Abnormal filling with delayed flow propagation
Relation between symptomatology and diastolic function Grade 1 (abnormal relaxation): may have dyspnoea on moderate or extreme exertion; may dev CCF symptoms if atrial contraction lost e.g. AF Grade 2 (increased filling pressure) may have symptom with mild moderate exertion Grade 3 (restrictive reversible filling pattern) symptom at rest or mild exertion Grade 4 (restrictive irreversible) data showed increased mortality
Diagnostic Approach for HFpEF
Angiotensin Receptor Blockers in HFpEF Blocks Angiotensin II which promotes cardiomyocyte hypertrophy Blocks association of AT II with AT I receptor 2 large trials: 1. Candesartan in Heart Failure Reduction in Mortality (CHARM)- Preserved trial : randomized 3,023 patients, NYHA function class II IV, LVEF= 40%. Benefit in reduction of heart failure hospitalisation vs placebo 2. I-PRESERVE: 4,128 patients aged 60 years or above with HF, LVEF at least 45%, NYHA class II IV symptoms with an HF hospitalization 6 months prior to enrolment, or ongoing NYHA class III or IV symptoms without hospitalization. No significant diff vs placebo.
Angiotensin Receptor Neprilysin Inhibitor (Valsartan/ Sacubitril) vs Valsartan alone in HFpEF (n= 266): Significant reduction of NT-proBNP from baseline to week 12 Improvement in LA remodeling and NYHA class at 36 weeks
PARAGON-HF Use of Entresto (valsartan/sacubitril) in HFpEF Study of 4300 pts Results in 2019
The Role of Statin? Prospective study of HFpEF patients (EF> 50%): matched population of 2,074 statin users and 2,074 non-statin users Use of statin associated with improved outcome: higher rate of 1-year survival (85.1% vs 80.9%, HR 0.80; 95% CI 0.72 0.98, P = 0.01). reduced CV death (HF 0.86; 95% CI 0.75 0.98; P = 0.026) and reduced composite all-cause mortality (HR 0.89; 95% CI 0.82 0.96; P = 0.003) Alehagen et al. Circ Heart Fail. 2015;8(5):862 870)
Role of Statin ACCF/AHA HF guidelines support use of statin therapy for patients with known atherosclerotic disease, but statins are not currently recommended for the treatment of HF alone in the absence of other indications
2013ACCF/AHA Guideline for Management of Heart Failure
Management of HFpEF Careful fluid management (weight checks) Restrict sodium intake Close examination of LV geometry, valvular function and pericardial disease Consider exercise test when diagnosis is unclear Aggressive control of heart rate in AF and treatment of ischemia Be mindful of betablockade in presence of chronotopic incompetence and RV dysfunction Vasodilators and Spironolactone may have advantages in loading and stiffness
Consider Entity of HFpEF Older Women Hypertension Obesity Atrial Fibrillation
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