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Keith Miller MD
Diastolic Heart Failure orHeart Failure with Preserved Ejection Fraction
Diastolic Heart FailureRisk Factors
Common Risk Factors
•Aging
•Female gender
•Obesity
•Hypertension
•Diabetes mellitus
•Coronary artery disease
•Chronic kidney disease
•Aortic stenosis
Uncommon Risk Factors
•Myocardial disorders
•Amyoloidosis
•Sarcoidosis
•Fatty infiltration
•Idiopathic cardiomyopathy
•Hypertrophic cardiomyopathy
•Hypereosinophilic syndrome
•Hemochromatosis
•Glycogen storage disease
•Pericardial disorders
•Constrictive pericarditis
•Effusive-constrictive pericarditis
•Pericardial effusion
23%
10%
67%
Women
Normal (≥≥≥≥ 55%)
Mildly Reduced
(45% - 54%)
Moderately (30-
44%) or severely
reduced (< 30%)
27%
42%
31%
Men
Ejection Fraction in Patients With Chronic Heart Failure
Cardiovascular Health Study (CHS), n=4842
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Distribution of ejection fraction (EF) over time.
Benjamin A. Steinberg et al. Circulation. 2012;126:65-75
J Am Coll Cardiol. 2014;63(5):407-416. doi:10.1016/j.jacc.2013.10.063
Cardiovascular and Noncardiac Risk Factors in the Development and Progression of PDD and HFpEF
Cardiovascular risk factors contribute to the development of pre-clinical diastolic dysfunction (PDD) (stage B). Both cardiovascular
and noncardiac risk factors contribute to the progression from PDD to symptomatic heart failure with preserved ejection fraction
(HFpEF) (stage C/D). Although survival decreases dramatically in symptomatic heart failure, the duration of stages A and B heartfailure with regards to survival remains to be fully elucidated.
Figure Legend:
Heart Failure with preserved Ejection Fraction (HFpEF)Prevention
• Blood pressure control
• HTN is a major RF for both HFrEF and HFpEF
• BP treatment reduces risk of incident HF by
approximately 50%
• NNT 52 to 125 (SPRINT) trial to prevent one HF event
• 150 doctors with patient panels of 2,000 to 3,000
(?conservatively 200 patients each (30% prevalence
of HTN) at high risk of developing CHF??)
• 30,000 patients at risk
• Could collectively preventF
• 240 new cases of HF (NNT 125)
• 577 new cases of HF (NNT 52)
• And that’s just treatment of HTN!
HOPE - Secondary and Other Endpoint Results
16
6.2
3.3
9.2
3.7
18.6
7.4
3.8
11.7
5.3
0
5
10
15
20
25
% w
ith
an
eve
nt
Ramipril
Placebo
Revascularization DM
Complications
New diagnosis of
Diabetes Mellitus
16% Risk Reduction
p<0.001
16% Risk Reduction
p=0.03
23% Risk Reduction
p<0.001
HF
Hospitalization
Heart Failure
N Engl J Med, January 20, 2000
13% Risk Reduction
p=0.19
32% Risk Reduction
p=0.002
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Role of Diuretics in the Prevention of Heart Failure
• ALLHAT study of 33,357 high-risk
hypertensive patients >55 years
• Excluded patients with history of HF
• HF occurred in 1773 patients over
4.9 years of follow up
• Over the first year, chlorthalidone
was significantly more effective at
prevention of HF than amlodipine
and lisinopril
• After the first year, chlorthalidone
was more effective at prevention of
HF than amlodipine but not different
than lisinopril
Davis, et al., Circulation. 2006;113:2201-2210.
SPRINT trial: Intensive BP control associated with a 38% reduction in HF incidence
Heart Failure with preserved Ejection Fraction (HFpEF)Prevention
J Am Coll Cardiol. 2014;63(5):407-416. doi:10.1016/j.jacc.2013.10.063
Cardiovascular and Noncardiac Risk Factors in the Development and Progression of PDD and HFpEF
Cardiovascular risk factors contribute to the development of pre-clinical diastolic dysfunction (PDD) (stage B). Both cardiovascular
and noncardiac risk factors contribute to the progression from PDD to symptomatic heart failure with preserved ejection fraction
(HFpEF) (stage C/D). Although survival decreases dramatically in symptomatic heart failure, the duration of stages A and B heartfailure with regards to survival remains to be fully elucidated.
Figure Legend:
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Heart Failure with preserved Ejection Fraction (HFpEF)
Four main points:Why HFpEF? What happened to DHF
Diagnosis
Prevention: The best option
Management:
Pharmacologic
Monitoring/Surveillance
HFrEF Therapies with little efficacy in HFpEF
ACE-Inhibitor (PEP CHF)
EHJ 2006
ARB (IPRESERVE)
NEJM 2008
Beta-Blockers (OPTIMIZE-HF) JACC 2009
Aldosterone AntagonistsTOPCAT trial
Figure 1. Kaplan–Meier Plot of Time to the First Confirmed Primary-Outcome Event.
The primary outcome was a composite of death from cardiovascular causes,
aborted cardiac arrest, or hospitalization for the management of heart failure.
The inset shows the same data on an expanded y axis. (NEJM 2014)
Results by
Region of
Enrollment
(Circ 2015)
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Heart Failure with preserved EFGuideline Directed Medical Therapy
(Circulation. 2013;128:e240-e327.)
2013 ACCF/AHA Guidelines for Management of Heart Failure
HFpEF Therapy
No approved pharacologic therapies to reduce hospitalization or mortality for HFpEF
Guideline-directed management is limited to diuretics and treatment of comorbidities
ACE-Is and ARBs not effective in reducing mortality
Beta-blockers have not shown benefits
Spironolactone improves DD and LVH, but not clinical outcomes
Exercise training in HFpEF improves symptoms and QOL
CardioMEMS PA pressure monitoring reduces hospitalization
HFpEF Therapy
“Considering its prevalence and outcomes, future projections, and lack of effective therapies, HFpEF represents the single largest unmet need in cardiovascular medicine.”
--Developing Therapies for Heart Failure with Preserved Ejection Fraction: Current State and Future Directions
J Am Coll Cardiol HF 2014;2:97–112
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New Management Strategies for HFpEF
I.) Drug TherapyA. PARAGON-HF – Entresto
II.) SurveillanceA. CardioMEMSB. SMILE – lung fluid status monitoringC. Cardiospire
A Novel Approach to Monitoring Pulmonary Congestion in Heart Failure: Initial Animal and Clinical Experiences Using Remote Dielectric Sensing Technology