Previous NYHA I with normal systolic function Now progressive dyspnea with exertion ER: AFIB at 120 bpm, Pulm Edema

Transcription

1 Diastolic Heart Failure Is A Cardiac Problem Debate Hanan B. ALBackr, MBBS,FRCPC Assistant professor of Medicine Cardiology consultant, echocardiography King Fahad Cardiac Center, KKUH College of Medicine, King Saud University, Riyadh 1

2 CASE 62 yo F with HTN & AFIB Previous NYHA I with normal systolic function Now progressive dyspnea with exertion ER: AFIB at 120 bpm, Pulm Edema Case scenario A 68-year-old female has exertional breathlessness, ankle swelling and a cough. 2 days H/O fever Past medical history: She has type 2 diabetes but no previous cardiac history. On examination You find ankle oedema, and 2 cm hepatomegaly Hypertension, BP=190/95 On chest examination: Bilateral basal crackels You suspect heart failure ± bronchopneumonia The BNP level is 300 pg/ml, what would you do next? 2

3 Answer: You would refer the patient to have specialist assessment and echocardiography The echocardiogram shows no evidence of left ventricular systolic dysfunction, Echocardiogram 3

4 4

5 So the cardiology specialist suggests that the patient has heart failure with preserved ejection fraction?? or Diastolic heart failure??? The specialist advises the introduction of a diuretic. Start ACE inhibitor therapy at a low dose and titrate upwards at short intervals (for example, every 2 weeks) until the optimal tolerated or target dose is achieved. Circulation September 20,

6 DHF OR What is it? How common? Dignosis!! How serious? How to treat it! ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. 6

7 Circulation September 20, Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of adults with heart failure Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. 7

8 The 2010 Heart Failure Society of America Comprehensive Heart Failure Practice Guideline HF is a syndrome caused by cardiac dysfunction, generally resulting from myocardial muscle dysfunction or loss and characterized by either LV dilation or hypertrophy or both. Whether the dysfunction is primarily systolic or diastolic or mixed, it leads to neurohormonal and circulatory abnormalities, usually resulting in characteristic symptoms such as fluid retention, shortness of breath, and fatigue, especially on exertion ACCF/AHA Guideline for the Management of Heart Failure Developed in Collaboration With the American Academy of Family Physicians, American College of Chest Physicians, Heart Rhythm Society, and International Society for Heart and Lung Transplantation Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation American College of Cardiology Foundation and American Heart Association, Inc. 8

9 Definition of Heart Failure Classification Ejection Fraction Description I. Heart Failure with Reduced Ejection Fraction (HFrEF) II. Heart Failure with Preserved Ejection Fraction (HFpEF) 40% Also referred to as systolic HF. Randomized clinical trials have mainly enrolled patients with HFrEF and it is only in these patients that efficacious therapies have been demonstrated to date. 50% Also referred to as diastolic HF. Several different criteria have been used to further define HFpEF. The diagnosis of HFpEF is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF. To date, efficacious therapies have not been identified. a. HFpEF, Borderline 41% to 49% These patients fall into a borderline or intermediate group. Their characteristics, treatment patterns, and outcomes appear similar to those of patient with HFpEF. b. HFpEF, Improved >40% It has been recognized that a subset of patients with HFpEF previously had HFrEF. These patients with improvement or recovery in EF may be clinically distinct from those with persistently preserved or reduced EF. Further research is needed to better characterize these patients. Treatment of Stages A to D Treatment for Stage C HFpEF JACC Vol. 62, No. 16, 2013 Yancy et al. October 15, 2013:e ACCF/AHA Heart Failure Guideline 9

10 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 I C Coronary revascularization for patients with CAD in whom angina or demonstrable myocardial ischemia is IIa C present despite GDMT Management of AF according to published clinical practice guidelines for HFpEF to improve symptomatic IIa C HF Use of beta-blocking agents, ACE inhibitors, and ARBs for hypertension in HFpEF IIa C ARBs might be considered to decrease hospitalizations in HFpEF IIb B Nutritional supplementation is not recommended in HFpEF JACC Vol. 62, No. 16, 2013 Yancy et al. October 15, 2013:e ACCF/AHA Heart Failure Guideline III: No Benefit C Prevalence of diastolic dysfunction unknown, as asymptomatic disease most common 10

11 500,000 new people with heart failure each year 1/3 diastolic heart failure 1/3 systolic heart failure 1/3 mixture Frequency of heart failure with normal systolic function 11

12 Progression of Left Ventricular Diastolic Dysfunction and Risk of Heart Failure JAMA. 2011;306(8): Objective To measure changes in diastolic function over time and to determine the relationship between diastolic dysfunction and the risk of subsequent heart failure. Main Outcome Measures Incident heart failure From: Progression of Left Ventricular Diastolic Dysfunction and Risk of Heart Failure JAMA. 2011;306(8): doi: /jama

13 From: Progression of Left Ventricular Diastolic Dysfunction and Risk of Heart Failure JAMA. 2011;306(8): doi: /jama Results Over 4 ±0.3 years diastolic dysfunction prevalence increased from 23.8% to 39.2% (P <0.001). Diastolic function grade worsened in 23.4% of participants, was unchanged in 67.8%, and improved in 8.8%. Worsened diastolic dysfunction was associated with age 65 years. 13

14 Results During 6.3 ±2.3 years of additional follow up, heart failureoccurred in 2.6%,7.8% and 12.2% of persons whose diastolic function normalized or remained normal, remained or progressed to milddysfunction, or remained or progressed to moderate severe dysfunction, respectively. (P <0.001) Diastolic dysfunction was associated with incident heart failure after adjustment for age, hypertension, diabetes, and coronary disease. Conclusions In a population based cohort undergoing 4 years of follow up, prevalence of diastolic dysfunction increased. Diastolic dysfunction was associated with development of heart failure during 6 years of subsequent follow up. 14

15 Owan T et al. N Engl J Med 2006;355:

16 Heart Failure with Preserved Ejection Fraction. Owan T et al. N Engl J Med 2006;355: Secular Trends in the Prevalence of Heart Failure with preseved EFPreserved Ejection Fraction Owan T et al. N Engl J Med 2006;355:

17 Kaplan-Meier Survival Curves for Patients with Heart Failure and Preserved or Reduced Ejection Fraction Owan T et al. N Engl J Med 2006;355: Diastolic Heart Failure Diagnosis No consensus on diagnostic criteria Vasan etal. Circulation 2000;101:2118 Definite vs Probable Diastolic CHF 1. Clinical evidence of raised LVEDP 2. Normal LV systolic function (EF > 50%) 3. Objective evidence of diastolic dysfunction Elevated LVEDP on cardiac catheterization E:A reversal with prolonged Decel n Time (>240) 17

18 Diagnostic Criteria: HF with Reduced Versus HF with Preserved EF. Journal of Cardiac Failure Vol. 16 No Heart Failure with Preserved Ejection Fraction A substantial number of patients with heart failure (HF) have preserved left ventricular ejection fraction (LVEF), variably defined as an LVEF 40%, 45%, or 50%. When these patients have invasive or non invasive evidence of abnormal diastolic function (either abnormal relaxation, filling or stiffness) they are said to have diastolic HF Gaasch WH. Diagnosis and treatment of heart failure based on left ventricularsystolic or diastolic dysfunction. JAMA 1994;271:1276e80. Smith GL, Masoudi FA, Vaccarino V, Radford MJ, Krumholz HM.Outcomes in heart failure patients with preserved ejection fraction:mortality, readmission, and functional decline. J Am Coll Cardiol 2003;41:1510e8. 4Konstam MA. "Systolic and diastolic dysfunction" in heart failure? Time for a new paradigm. J Card Fail 2003;9:1e3. 18

19 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines The definition of HF has now expanded to: a. HF with reduced ejection fraction (HFrEF, EF 40%) b. HF failure with preserved ejection fraction (HFpEF, EF 50%) c. HFpEF, borderline (EF 41 49%) d. HFpEF, improved (EF >40%) Aim for control of systolic and diastolic blood pressures, as well as volume status, to treat HFpEF. Sequence of Mechanical Events in Diastole Notomi, Y. et al. J Am Coll Cardiol Img 2009;2:

20 Mechanism of LV Twist Bertini, M. et al. J Am Coll Cardiol Img 2009;2: Left ventricular rotation (LVrot) at apical and basal levels during systole by "overlaid" speckle tracking images Notomi, Y. et al. J Am Coll Cardiol 2005;45:

21 Diastolic Heart Failure Prognosis Annual mortality 5 8% for diastolic HF vs 10 15% with systolic HF; however morbidity rates the same Prevalence and mortality increased with age Peak MVO2 most accurate predictor of prognosis Mortality and Morbidity. 21

22 From: Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: Prevalence and mortality in a population based cohort J Am Coll Cardiol. 1999;33(7): doi: /s (99) Figure Legend: The distribution of left ventricular ejection fraction (LVEF) values among men and women with congestive heart failure is displayed in the figure. Twenty seven of 40 men (67.5%) had a reduced LVEF (<0.50), compared with only nine of 33 women (27%). Date of download: 11/11/2013 Copyright The American College of Cardiology. All rights reserved. From: Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: Prevalence and mortality in a population based cohort J Am Coll Cardiol. 1999;33(7): doi: /s (99) Figure Legend: Kaplan Meier survival plots of CHF patients with normal and reduced LVEF are displayed. The overall survival of CHF subjects with reduced LVEF is worse than that of CHF subjects who have a normal LVEF. This comparison does not account for gender differences in the composition of the two groups. Abbreviations as in Figure 2. Date of download: 11/11/2013 Copyright The American College of Cardiology. All rights reserved. 22

23 Results CHF cases (51%) had a normal LVEF; 36 (49%) had a reduced LVEF. During a median follow up of 6.2 years, CHF cases with normal LVEF experienced an annual mortality of 8.7% versus 3.0% for matched control subjects Congestive heart failure cases with reduced LVEF had an annual mortality of 18.9% versus 4.1% for matched control subjects Conclusion Normal LV systolic function is often found in persons with CHF in the community and is more common in women than in men. Although CHF cases with normal LVEF have a lower mortality risk than cases with reduced LVEF, they have a fourfold mortality risk compared with control subjects who are free of CHF. 23

24 Could diastolic parameters be important for prognosis? Take home message left ventricular diastolic dysfunction is highly prevalent, tends to worsen over time, and isassociated with advancing age. Worsening diastolic function can be detected even in apparently healthy persons. The persistence or progression of diastolic dysfunction is an independent risk factor for heart failure in the elderly. 24