scompenso cardiaco a frazione di eiezione preservata - heart failure with preserved ejection...
TRANSCRIPT
Quale terapia nellrsquoHFpEF
Plinio Fabiani (Lido di Camaiore)
Definition of heart failure with preserved (HFpEF) mid-range (HFmrEF) and reduced ejection fraction(HFrEF)
European Heart Journal (2016) 37 2129ndash2200
The Changing Landscape of Heart Failure The Projected Trajectory of HFpEF in Hospitalized Heart Failure Patients
Curr Heart Fail Rep 2013 Dec10(4)401-10Oktay AA Rich JD Shah SJ
HFpEF amp HFrEF Similarly high mortality
bull 1 Owan et al N Engl J Med 2006355251ndash9 2 Blanche et al Swiss Med Wkly 201014066ndash72
bull 3 Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) Eur Heart J 2012331750ndash7
Su
rviv
al
10
08
06
04
02
0
0 1 2 3 4 5Year
HFrEF (LVEF lt50)
HFpEF (LVEF ge50)
p=003
Survival rate among patients with a discharge diagnosis of HF in the USA was slightly higher among patients with HFpEF than those with HFrEF between 1987ndash20011
Respective mortality rates were 29 and 32 at 1 year and 65 and 68 at 5 years
HFpEF is associated with significant morbidity and mortality despite having a slightly higher survival rate compared with HFrEF23
Shah JS et AlCirculation 201613473-90
Chest wall restriction reduced vital capacityimpaired ventilation and diffusionObstructive sleep apneaPulmonary hypertension
Direct and indirect myocardial lipotoxicityWorsened cardiac mechanicsDiastolic dysfunction increased filling pressuresvolume overload increased afterload
Non-alcoholic fatty liver diseasePromotes generalizedinflammatory stat
Inflammatory cytokinesAdverse neurohormonesInsulin resistanceIncreased BNP clearance
Direct toxic effects of perinephric fatGlomerulomegaly withglomerular dysfunction
Increased adipose infiltrationAltered insulin signalingDecreased capillary density impaired perfusionDecreased diffusive O2 transportMitochondrial dysfunction
The HFpEF Obesity PhenotypeThe Elephant in the Room
Kitzman DW Shah SJJACC 68(2) 200 2016
Ponikowski EHJ (2016) 37 2129ndash200
Cyclic GMP Pathway has beenProposed as a Potential Mediator of HFpEF
PDE5 InhibitorsRELAX Trial
Neprilysin Inhibitor
PARAMOUNT
NitratesNEAT-HFpEF
sGC StimulatorssGC Activators
LEPHT Trial
Pandey J Am Coll Cardiol 2017691129ndash42
HFrEF
HFpEF
Definition of heart failure with preserved (HFpEF) mid-range (HFmrEF) and reduced ejection fraction(HFrEF)
European Heart Journal (2016) 37 2129ndash2200
The Changing Landscape of Heart Failure The Projected Trajectory of HFpEF in Hospitalized Heart Failure Patients
Curr Heart Fail Rep 2013 Dec10(4)401-10Oktay AA Rich JD Shah SJ
HFpEF amp HFrEF Similarly high mortality
bull 1 Owan et al N Engl J Med 2006355251ndash9 2 Blanche et al Swiss Med Wkly 201014066ndash72
bull 3 Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) Eur Heart J 2012331750ndash7
Su
rviv
al
10
08
06
04
02
0
0 1 2 3 4 5Year
HFrEF (LVEF lt50)
HFpEF (LVEF ge50)
p=003
Survival rate among patients with a discharge diagnosis of HF in the USA was slightly higher among patients with HFpEF than those with HFrEF between 1987ndash20011
Respective mortality rates were 29 and 32 at 1 year and 65 and 68 at 5 years
HFpEF is associated with significant morbidity and mortality despite having a slightly higher survival rate compared with HFrEF23
Shah JS et AlCirculation 201613473-90
Chest wall restriction reduced vital capacityimpaired ventilation and diffusionObstructive sleep apneaPulmonary hypertension
Direct and indirect myocardial lipotoxicityWorsened cardiac mechanicsDiastolic dysfunction increased filling pressuresvolume overload increased afterload
Non-alcoholic fatty liver diseasePromotes generalizedinflammatory stat
Inflammatory cytokinesAdverse neurohormonesInsulin resistanceIncreased BNP clearance
Direct toxic effects of perinephric fatGlomerulomegaly withglomerular dysfunction
Increased adipose infiltrationAltered insulin signalingDecreased capillary density impaired perfusionDecreased diffusive O2 transportMitochondrial dysfunction
The HFpEF Obesity PhenotypeThe Elephant in the Room
Kitzman DW Shah SJJACC 68(2) 200 2016
Ponikowski EHJ (2016) 37 2129ndash200
Cyclic GMP Pathway has beenProposed as a Potential Mediator of HFpEF
PDE5 InhibitorsRELAX Trial
Neprilysin Inhibitor
PARAMOUNT
NitratesNEAT-HFpEF
sGC StimulatorssGC Activators
LEPHT Trial
Pandey J Am Coll Cardiol 2017691129ndash42
HFrEF
HFpEF
The Changing Landscape of Heart Failure The Projected Trajectory of HFpEF in Hospitalized Heart Failure Patients
Curr Heart Fail Rep 2013 Dec10(4)401-10Oktay AA Rich JD Shah SJ
HFpEF amp HFrEF Similarly high mortality
bull 1 Owan et al N Engl J Med 2006355251ndash9 2 Blanche et al Swiss Med Wkly 201014066ndash72
bull 3 Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) Eur Heart J 2012331750ndash7
Su
rviv
al
10
08
06
04
02
0
0 1 2 3 4 5Year
HFrEF (LVEF lt50)
HFpEF (LVEF ge50)
p=003
Survival rate among patients with a discharge diagnosis of HF in the USA was slightly higher among patients with HFpEF than those with HFrEF between 1987ndash20011
Respective mortality rates were 29 and 32 at 1 year and 65 and 68 at 5 years
HFpEF is associated with significant morbidity and mortality despite having a slightly higher survival rate compared with HFrEF23
Shah JS et AlCirculation 201613473-90
Chest wall restriction reduced vital capacityimpaired ventilation and diffusionObstructive sleep apneaPulmonary hypertension
Direct and indirect myocardial lipotoxicityWorsened cardiac mechanicsDiastolic dysfunction increased filling pressuresvolume overload increased afterload
Non-alcoholic fatty liver diseasePromotes generalizedinflammatory stat
Inflammatory cytokinesAdverse neurohormonesInsulin resistanceIncreased BNP clearance
Direct toxic effects of perinephric fatGlomerulomegaly withglomerular dysfunction
Increased adipose infiltrationAltered insulin signalingDecreased capillary density impaired perfusionDecreased diffusive O2 transportMitochondrial dysfunction
The HFpEF Obesity PhenotypeThe Elephant in the Room
Kitzman DW Shah SJJACC 68(2) 200 2016
Ponikowski EHJ (2016) 37 2129ndash200
Cyclic GMP Pathway has beenProposed as a Potential Mediator of HFpEF
PDE5 InhibitorsRELAX Trial
Neprilysin Inhibitor
PARAMOUNT
NitratesNEAT-HFpEF
sGC StimulatorssGC Activators
LEPHT Trial
Pandey J Am Coll Cardiol 2017691129ndash42
HFrEF
HFpEF
HFpEF amp HFrEF Similarly high mortality
bull 1 Owan et al N Engl J Med 2006355251ndash9 2 Blanche et al Swiss Med Wkly 201014066ndash72
bull 3 Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) Eur Heart J 2012331750ndash7
Su
rviv
al
10
08
06
04
02
0
0 1 2 3 4 5Year
HFrEF (LVEF lt50)
HFpEF (LVEF ge50)
p=003
Survival rate among patients with a discharge diagnosis of HF in the USA was slightly higher among patients with HFpEF than those with HFrEF between 1987ndash20011
Respective mortality rates were 29 and 32 at 1 year and 65 and 68 at 5 years
HFpEF is associated with significant morbidity and mortality despite having a slightly higher survival rate compared with HFrEF23
Shah JS et AlCirculation 201613473-90
Chest wall restriction reduced vital capacityimpaired ventilation and diffusionObstructive sleep apneaPulmonary hypertension
Direct and indirect myocardial lipotoxicityWorsened cardiac mechanicsDiastolic dysfunction increased filling pressuresvolume overload increased afterload
Non-alcoholic fatty liver diseasePromotes generalizedinflammatory stat
Inflammatory cytokinesAdverse neurohormonesInsulin resistanceIncreased BNP clearance
Direct toxic effects of perinephric fatGlomerulomegaly withglomerular dysfunction
Increased adipose infiltrationAltered insulin signalingDecreased capillary density impaired perfusionDecreased diffusive O2 transportMitochondrial dysfunction
The HFpEF Obesity PhenotypeThe Elephant in the Room
Kitzman DW Shah SJJACC 68(2) 200 2016
Ponikowski EHJ (2016) 37 2129ndash200
Cyclic GMP Pathway has beenProposed as a Potential Mediator of HFpEF
PDE5 InhibitorsRELAX Trial
Neprilysin Inhibitor
PARAMOUNT
NitratesNEAT-HFpEF
sGC StimulatorssGC Activators
LEPHT Trial
Pandey J Am Coll Cardiol 2017691129ndash42
HFrEF
HFpEF
Shah JS et AlCirculation 201613473-90
Chest wall restriction reduced vital capacityimpaired ventilation and diffusionObstructive sleep apneaPulmonary hypertension
Direct and indirect myocardial lipotoxicityWorsened cardiac mechanicsDiastolic dysfunction increased filling pressuresvolume overload increased afterload
Non-alcoholic fatty liver diseasePromotes generalizedinflammatory stat
Inflammatory cytokinesAdverse neurohormonesInsulin resistanceIncreased BNP clearance
Direct toxic effects of perinephric fatGlomerulomegaly withglomerular dysfunction
Increased adipose infiltrationAltered insulin signalingDecreased capillary density impaired perfusionDecreased diffusive O2 transportMitochondrial dysfunction
The HFpEF Obesity PhenotypeThe Elephant in the Room
Kitzman DW Shah SJJACC 68(2) 200 2016
Ponikowski EHJ (2016) 37 2129ndash200
Cyclic GMP Pathway has beenProposed as a Potential Mediator of HFpEF
PDE5 InhibitorsRELAX Trial
Neprilysin Inhibitor
PARAMOUNT
NitratesNEAT-HFpEF
sGC StimulatorssGC Activators
LEPHT Trial
Pandey J Am Coll Cardiol 2017691129ndash42
HFrEF
HFpEF
Chest wall restriction reduced vital capacityimpaired ventilation and diffusionObstructive sleep apneaPulmonary hypertension
Direct and indirect myocardial lipotoxicityWorsened cardiac mechanicsDiastolic dysfunction increased filling pressuresvolume overload increased afterload
Non-alcoholic fatty liver diseasePromotes generalizedinflammatory stat
Inflammatory cytokinesAdverse neurohormonesInsulin resistanceIncreased BNP clearance
Direct toxic effects of perinephric fatGlomerulomegaly withglomerular dysfunction
Increased adipose infiltrationAltered insulin signalingDecreased capillary density impaired perfusionDecreased diffusive O2 transportMitochondrial dysfunction
The HFpEF Obesity PhenotypeThe Elephant in the Room
Kitzman DW Shah SJJACC 68(2) 200 2016
Ponikowski EHJ (2016) 37 2129ndash200
Cyclic GMP Pathway has beenProposed as a Potential Mediator of HFpEF
PDE5 InhibitorsRELAX Trial
Neprilysin Inhibitor
PARAMOUNT
NitratesNEAT-HFpEF
sGC StimulatorssGC Activators
LEPHT Trial
Pandey J Am Coll Cardiol 2017691129ndash42
HFrEF
HFpEF
Ponikowski EHJ (2016) 37 2129ndash200
Cyclic GMP Pathway has beenProposed as a Potential Mediator of HFpEF
PDE5 InhibitorsRELAX Trial
Neprilysin Inhibitor
PARAMOUNT
NitratesNEAT-HFpEF
sGC StimulatorssGC Activators
LEPHT Trial
Pandey J Am Coll Cardiol 2017691129ndash42
HFrEF
HFpEF
Cyclic GMP Pathway has beenProposed as a Potential Mediator of HFpEF
PDE5 InhibitorsRELAX Trial
Neprilysin Inhibitor
PARAMOUNT
NitratesNEAT-HFpEF
sGC StimulatorssGC Activators
LEPHT Trial
Pandey J Am Coll Cardiol 2017691129ndash42
HFrEF
HFpEF
Pandey J Am Coll Cardiol 2017691129ndash42
HFrEF
HFpEF