Heart Failure with Preserved EF

Dino Recchia, MD, FACC, FHFSA

Diastolic HF 2004 “Diastolic HF” c.2004

Aurigemma G, et al. NEJM 2004

1/3 - 2/3 HFpEF pts do NOT have LVH

1/3 pts in HFpEF trials had normal diastolic function

HFpEF 2018 Biological Phenotypes

HFpEF Prevalence Increasing

44% 31%

15%

13%

41% 56%

1985-1994 2005-2014

EF<40% EF 40-50% EF>50%

Adapted from Ramachandran et al JACC:Cardiovasc Imaging 2017

Chun et al Circ Heart Fail 2012

N = 8543

HFpEF is not Benign

Walter et al Eur Heart J 2014

HFpEF: A Multisystem Disease

Cardiovascular Reserve is Impaired in HFpEF

Impaired Chronotropic

Response

Impaired Peripheral

Vasodilation

Impaired Stroke Volume

Reserve

Borlaug et al Circ Heart Fail 2010

Therapeutic Failures in HFpEF

Class 1 recommendations for HFrEF = 7

Class 1 recommendations for HFpEF = 0

Spironolactone in HFpEF TOPCAT Trial

• International study

• N=3,445

• Symptomatic HFpEF

• EF >45%

• Spironolactone vs placebo

• Endpoint CV death or HF hospitalization

Pitt et al NEJM 2014

Spironolactone in HFpEF

Pfeffer et al Circ 2015

Regional Variation in Outcomes

Regional Variation in Drug Metabolite

Treatment X Benefits A >>> B > C

C

B A

Treatment X has no

overall benefit

Why have HFpEF Treatments Failed?

Guazzi M Circ Heart Fail 2014

Cluster Analysis

Shah et al Circulation 2015

HFpEF Phenotype & Prognosis

Categories of HFpEF

• “Garden-variety” HFpEF (HTN, DM, obesity, CKD)

• CAD-HFpEF

• Right heart failure-HFpEF

• A-fib predominant HFpEF

• HCM-like HFpEF

• High-output HFpEF

• Valvular HFpEF (multiple moderate lesions)

• Rare causes of HFpEF

Hwang et al J Am Coll Cardiol 2014

HFpEF & CAD

• Pts who were discharged with HFpEF and had both an echo and cath within 1 year

• Excluded pts with low EF, ACS, valve disease, HCM, and restrictive CM

• 376 pts eligible

• Results of stress testing, echo, cath reviewed

• Follow up to 10 years

HFpEF an Stress Testing

• 2/3 had CAD • 1/3 of CAD pts had 3V CAD

Hwang et al J Am Coll Cardiol 2014

Hwang et al J Am Coll Cardiol 2014

HFpEF & CAD

Obesity and HFpEF

Ndumele et al J Am Heart Assoc 2016

Risk adjusted for HTN, DM, HLP,

tobacco, physical inactivity

HFpEF Obesity Phenotype

Kitzman et al J Am Coll Cardiol 2016

Diet & Exercise Work Diet and exercise work!

Kitzman D, et al. JAMA 2016

AT = aerobic exercise training, CR = caloric restriction

New Concepts in HFpEF

• Role of the systemic vasculature

• Importance of pulmonary HTN

• “Interventional” therapies for HFpEF

• New options for cardiac amyloidosis

Pulse Wave Velocity & Premature Wave Reflections

• PWV is a measure of aortic stiffness

• Systolic wave reflections occur and are related to PWV

• Ideal PWV ‒ All wave reflections occur during

diastole when aortic valve is closed ‒ Augments coronary perfusion ‒ No change in afterload on the heart

• Increased PWV

‒ Premature wave reflections occur in late systole leading to increased afterload on the heart

Wave Reflections & Exercise Intolerance

Pulmonary HTN & HFpEF

Interatrial Shunt Device for HFpEF

Improving LV Compliance in HFpEF

Hemodynamics of Pericardiotomy

HFSA 22nd Annual Scientific Meeting

Cardiac Amyloidosis: Often Misdiagnosed and Undertreated

Page 2 of 39

HFSA 22nd Annual Scientific Meeting

Cardiac Amyloidosis: Often Misdiagnosed and Undertreated

Page 2 of 39

HFSA 22nd Annual Scientific Meeting

Cardiac Amyloidosis: Often Misdiagnosed and Undertreated

Page 2 of 39

Restrictive Cardiomyopathy

* *

Cardiac Amyloid – wtTTR Variant

• Most common in white males

• Seen at autopsy in 25% HFpEF pts over 85

• Found in 13% of hospitalized pts with HFpEF >60

• 12% pts undergoing TAVR for AS with low gradient

• Bilateral carpal tunnel syndrome and spinal stenosis seen in 50% cases

Cardiac Amyloid – mTTR Variant

• >100 mutations leading to various familial type amyloid syndromes: ‒ Familial amyloid polyneuropathy ‒ Familial amyloid cardiomyopathy

• Val122I mutation most common in US seen in African

Americans with 3-4% heterozygote carriers

• Restrictive CM with minimal neuropathy often misdiagnoses as hypertensive heart disease

Sensitivity 85-90%

Specificity 85-90%

Sensitivity 97% for TTR

Specificity 99% for TTR

Sensitivity 99% Sensitivity 30%

Specificity 75%

Management of Amyloid CM

• Difficult due to narrow window between too high and too low filling pressures

• Torsemide preferred diuretic

• No verapamil or diltiazem

• Avoid digoxin

• Maintain NSR

• New treatment options

New Treatment Option for TT Amyloid CM Tafamadis

• 30% reduction in all cause mortality

• 32% reduction in hospitalizations

• 12-18 months rx re needed before observing the benefit

• Significant improvement in quality of life scores

• Early detection is key

Maurer et al NEJM 2018

Thank You