scompenso cardiaco con frazione di eiezione...
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Scompenso Cardiaco con frazione di eiezione preservata
Dott.ssa C.RaineriDivisione di Cardiologia, Fondazione IRCCS Policlinico S.Matteo, Pavia
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ESC GUIDELINES European Heart Journal (2016) 37, 2129–2200
Definition of HFpEF
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Dhingra et al. Curr Heart Fail Rep 2014 11:354–365
Proportion of heart failure patients with preserved ejection fraction based on HF registries
Prevalence of patients with HFpEF
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28,820 participants from 3 community-based cohorts: 982 developed incident HFpEF during a median follow-up of 12 years.
Ho et al. Circ Heart Fail. 2016;9:e003116
Incidence of HFpEF
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The American Journal of Medicine 2016; 129: 635.e15-635.e26
5,046,879 hospitalizations with a diagnosis of acute heart failure in 2003-2012
Characteristics of Patients Hospitalized with HFpEF vs HFrEF
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The American Journal of Medicine 2016; 129: 635.e15-635.e26
Non cardiac co-morbidities in Patients Hospitalized with HFpEF
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The American Journal of Medicine 2016; 129: 635.e15-635.e26
Cardiovascular disease in pts with HFpEF vs HFrEF
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Rajalakshmi Santhanakrishnan et al. Circulation. 2016;133:484-492
Atrial Fibrillation Begets Heart Failure and Vice Versa
Framingham Heart Study participants with new-onset AF or HF between 1980 and 2012.
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Hwang et al. J Am Coll Cardiol 2014;63:2817–27
Impact of CAD on Survival in Patients With HFpEF
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Redfield. N Engl J Med 2016;375:1868-77
Pathophysiological Model of HFpEF
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Obokata et al. J Am Coll Cardiol 2019
Pathophysiologic contributors to HFpEF
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Reddy et Borlaug Current Problems in Cardiology 2016; 4: 2016, 145–188
The end diastolic pressure volume relationship in pts with HFpEF
left and upward shift of EDPVR → ↑ Diastolic LV filling press
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Borlaug et al Circ J 2014; 78: 20–32
HFpEF: ↑ PCWP/LVEDP and PAP with exercise
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sc-eFS : Stress-corrected endocardial fractional shorteningsc-mFS :Stress-corrected midwall fractional shortening
Borlaug et al. J Am Coll Cardiol. 2009; 54(5): 410–418
Systolic dysfunction in HFpEF
Load-Independent Measures Contractility
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Chronotropic incompetence in HFpEF
Borlaug et al Circ J 2014; 78: 20–32
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Myocardial Reserve Dysfunction in HFpEF
Circ Heart Fail. 2019;12:e006240
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Kawaguchi et al. Circulation. 2003;107:714-720
A-V couplingin HFpEF
Arterial elastance (Ea) and Ees are elevated in tandem in HFpEF
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A-V coupling
Combined ventricular-arterial stiffening leads to greater blood pressure lability, by creating a ‘high gain’ system—with amplified blood pressure changes for any alteration in preload or afterload
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• Prevalence varies (36-83%) depending on the population studied, the methods(echocardiography or RHC) and the hemodynamic criteria used to diagnosePH.
• Frequently associated with RV dysfunction and uncoupling with the pulmonary circulation.
Pulmonary Hypertension in HFpEF
Guazzi Heart Failure Clin 2018; 14: 297–309
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Pulmonary Hypertension and Outcomes in HFpEF
JAMA Cardiol. 2018;3(4):298-306
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Elevated PVR Are Associated With Increased Mortalityin the PH-HFpEF Cohort
JAMA Cardiol. 2018;3(4):298-306
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RV dysfunction in HFpEF
Melenovsky et al. Eur Heart J 2014;35: 3452–3462
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The American Journal of Medicine (2016) 129, 635.e15-635.e26
• In-hospital mortality in HFpEF ranges from 2.4% to 4.9%in observational studies, with slightly higher 30-day (5%) and 60–90 day (9.5%) mortality.
• 5 years mortality ranging from 53% to 74%.
• Annualized mortality : - 10-25% in observational studies- 4-5% in large HFpEF trials
Clinical Outcome of patients with HFpEF
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The survival of patients with HFpEF vs HFrEFMeta-analysis Global Group in Chronic Heart Failure
(MAGGIC)
European Heart Journal 2012; 33: 1750–1757
The primary outcome of death from any cause occurred in 2422 (23.4%) patientswith HF-PEF and in 8332 (26.3%) in those with HF-REF.
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J Am Coll Cardiol. 2017;70(20):2476–86.
39,982 patients from 254 hospitals who were admitted for HF between 2005 and 2009
Outcomes of Heart Failure
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Age-Related Outcomes of Patients With HFpEF
J Am Coll Cardiol 2019;74:601–12
pts with LVEF > 45% from 3 large HFpEF trials (TOPCAT, I-PRESERVE and CHARM Preserved )
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Causes of Death Across Age Strata
J Am Coll Cardiol 2019;74:601–12
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Eur Heart J 2019; 40, 3297–3317
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Eur Heart J 2019; 40, 3297–3317
Diagnostic Workup and Scoring System
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Eur Heart J 2019; 40, 3297–3317
Advanced work-up: Echo stress test
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Eur Heart J 2019; 40, 3297–3317
Advanced work-up:invasive haemodynamic Measurments
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Eur Heart J 2019; 40, 3297–3317
Aetiological work-up
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Chamsi-Pasha JACC Cardiovasc Imaging 2019
CMR in the Evaluation of Diastolic Dysfunction and Phenotyping of HFpEF
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CMR and HFpEF
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Treatment of HFpEF
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TOPCAT
Outcome trials in HFpEF
Clealand et al. Heart Fail Clinics 2014;10:511-523
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Angiotensin–Neprilysin Inhibition in HFpEFParagon-HF trial
N Engl J Med 2019;381:1609-20
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Curr Treat Options Cardio Med 2019; 21: 20
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In the absence of convincingtrial data, what should we do?
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Adamson et al. Circ Heart Fail. 2014;7:935-944
Primary hypothesis: hemodynamically guided HF management decreasesdecompensation leading to hospitalization.
Of the 550 patients enrolled in the study, 119 had left ventricular EF ≥40%
CHAMPION trial
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Exercise Training in HFpEF
Edelmann, et al. JACC 2011; 58: 1780-9
64 patients with HFpEF mean age 65 ± 7 years, 56% female.
Randomized (2:1) to supervisedendurance/resistance training in addition to usual care vs usual care
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Schwartzenberg, et al. J Am Coll Cardiol 2012;59:442–51
Need to be careful with vasodilators...