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Management of Heart Failure with Preserved Ejection Fraction Ivan Anderson, RIHVH Cardiology MD

Outline Review: What Heart Failure is and is Not Classification schema for CHF Disease mechanisms and phenotypes Medical management of stable/compensated Heart Failure with Preserved Ejection Fraction (HFpEF)

Causes for Elevated Natriuretic Peptide Levels Non-cardiac Advancing age Anemia Renal failure Pulmonary causes: obstructive sleep apnea, severe pneumonia, pulmonary hypertension Critical illness Bacterial sepsis Severe burns Toxic-metabolic insults, including cancer chemotherapy and envenomation

Classification of Heart Failure ACCF/AHA Stages of HF NYHA Functional Classification A At high risk for HF but without structural heart disease or symptoms of HF. None B Structural heart disease but without signs or symptoms of HF. I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. C Structural heart disease with prior or current symptoms of HF. I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF. III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF. D Refractory HF requiring specialized interventions. IV Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest.

2 Flights of Stairs

Early Atrial Filling (E wave) Late Atrial Filling from atrial contraction (A wave)

Echocardiography should not be used as a tie breaker to diagnose Heart Failure

RV LV RA LA Apical 4 Chamber View

1. Myopathic process in the left ventricle 4 2. Left atrial hypertension 2, 3 1 3. Left atrial enlargement 4. Pulmonary venous hypertension

Risk Scoring I IIa IIb III Validated multivariable risk scores can be useful to estimate subsequent risk of mortality in ambulatory or hospitalized patients with HF.

Risk Scores to Predict Outcomes in HF Risk Score Chronic HF All patients with chronic HF Seattle Heart Failure Model Reference (from full-text guideline)/link (204) / http://seattleheartfailuremodel.org Heart Failure Survival Score (200) / http://handheld.softpedia.com/get/health/calculator/hfss-calc- 37354.shtml CHARM Risk Score (207) CORONA Risk Score (208) Specific to chronic HFpEF I-PRESERVE Score (202) Acutely Decompensated HF ADHERE Classification and Regression Tree (CART) Model American Heart Association Get With the Guidelines Score EFFECT Risk Score (201) (206) / http://www.heart.org/heartorg/healthcareprofessional/getwiththeguidel ineshfstroke/getwiththeguidelinesheartfailurehomepage/get-with-the- Guidelines-Heart-Failure-Home- %20Page_UCM_306087_SubHomePage.jsp (203) / http://www.ccort.ca/research/chfriskmodel.aspx ESCAPE Risk Model and Discharge Score (215) OPTIMIZE HF Risk-Prediction Nomogram (216)

Treatment of HFpEF Recommendations COR LOE Systolic and diastolic blood pressure should be controlled according to published clinical practice guidelines I B Diuretics should be used for relief of symptoms due to volume overload Coronary revascularization for patients with CAD in whom angina or demonstrable myocardial ischemia is present despite GDMT Management of AF according to published clinical practice guidelines for HFpEF to improve symptomatic HF Use of beta-blocking agents, ACE inhibitors, and ARBs for hypertension in HFpEF ARBs might be considered to decrease hospitalizations in HFpEF Nutritional supplementation is not recommended in HFpEF I IIa IIa IIa IIb III: No Benefit C C C C B C

Pharmacological Treatment for Stage C HFpEF I IIa IIb III I IIa IIb III Systolic and diastolic blood pressure should be controlled in patients with HFpEF in accordance with published clinical practice guidelines to prevent morbidity. Diuretics should be used for relief of symptoms due to volume overload in patients with HFpEF. I IIa IIb III Coronary revascularization is reasonable in patients with CAD in whom symptoms (angina) or demonstrable myocardial ischemia is judged to be having an adverse effect on symptomatic HFpEF despite GDMT.

Pharmacological Treatment for Stage C HFpEF (cont.) I IIa IIb III Management of AF according to published clinical practice guidelines in patients with HFpEF is reasonable to improve symptomatic HF. I IIa IIb III The use of beta-blocking agents, ACE inhibitors, and ARBs in patients with hypertension is reasonable to control blood pressure in patients with HFpEF.

Pharmacological Treatment for Stage C HFpEF (cont.) I IIa IIb III The use of ARBs might be considered to decrease hospitalizations for patients with HFpEF. I IIa IIb III No Benefit Routine use of nutritional supplements is not recommended for patients with HFpEF.

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