1 William T. Abraham, MD, FACP, FACC, FAHA Professor of Medicine, Physiology, and Cell Biology Chief, Division of Cardiovascular Medicine Deputy Director, Davis Heart & Lung Research Institute The Ohio State University Columbus, Ohio Heart Failure Update: Diastolic Dysfunction Epidemiology of Symptomatic Heart Failure in the United States • ≈ 5 million Americans with heart failure • 400,000 - 700,000 new cases diagnosed/year • Most frequent cause of hospitalization in patients older than 65 years • Primary reason for 12 to 15 million office visits and 6.5 million hospital days each year • Causes or contributes to 250,000 deaths/year • 1-Year mortality rate is about 10-15% • 5-Year mortality rate approaches 50% Heart Failure Hospitalizations are Increasing 0 100,000 200,000 300,000 400,000 500,000 600,000 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 Discharges Women Men 0 100,000 200,000 300,000 400,000 500,000 600,000 '79 '81 '83 '85 '87 '89 '91 '93 '95 '97 Discharges Women Men CDC/NCHS: Hospital discharges include patients both living and dead. AHA Heart and Stroke Statistical Update 2001 Decompensated Heart Failure: The Major Contributor to Cost of Care Maintenance ($18 B) • Medications • Routine MD visits • Nonmedical care Surgical procedures to treat HF ($2 B) • Heart transplantation • Mechanical devices Episodes of decompensation ($36 B) • Hospital care • MD visits • ED visits • Dx testing Total HF cost: $56 billion O’Connell JB. Clin Cardiol 2000;23:III-6
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William T. Abraham, MD, FACP, FACC, FAHAProfessor of Medicine, Physiology, and Cell Biology
Chief, Division of Cardiovascular MedicineDeputy Director, Davis Heart & Lung Research Institute
The Ohio State UniversityColumbus, Ohio
Heart Failure Update:Diastolic Dysfunction
Epidemiology of Symptomatic Heart Failure
in the United States• ≈ 5 million Americans with heart failure• 400,000 - 700,000 new cases diagnosed/year• Most frequent cause of hospitalization in
patients older than 65 years• Primary reason for 12 to 15 million office visits
and 6.5 million hospital days each year• Causes or contributes to 250,000 deaths/year• 1-Year mortality rate is about 10-15%• 5-Year mortality rate approaches 50%
Heart Failure Hospitalizations are
Increasing
0
100,000
200,000
300,000
400,000
500,000
600,000
'79 '81 '83 '85 '87 '89 '91 '93 '95 '97
Dis
char
ges
WomenMen
0
100,000
200,000
300,000
400,000
500,000
600,000
'79 '81 '83 '85 '87 '89 '91 '93 '95 '97
Dis
char
ges
WomenMen
CDC/NCHS: Hospital discharges include patients both living and dead.AHA Heart and Stroke Statistical Update 2001
Decompensated Heart Failure: The Major
Contributor to Cost of CareMaintenance ($18 B)
• Medications• Routine MD visits• Nonmedical care
Surgical proceduresto treat HF ($2 B)
• Hearttransplantation
• Mechanicaldevices
Episodes ofdecompensation($36 B)
• Hospital care • MD visits• ED visits• Dx testing
Total HF cost: $56 billionO’Connell JB. Clin Cardiol 2000;23:III-6
2
Outcomes in Patients Hospitalized With Heart Failure
Median LOS: 6 daysN = 38,702Aghababian RV. Rev Cardiovasc Med 2002; 3:S3Jong P et al. Arch Intern Med 2002; 162:1689
0
25
50
75
100
20%
50%
30Days
6Months
Hospital Readmissions
0
25
50
75
100
12%
50%
30Days
12Months
33%
5Years
Mortality
Jain P et al., Am Heart J. 2003;145:S3-S17
Time
Func
tiona
l abi
lity
Acute event
With each event, hemodynamic alterations/myocardial injury contribute to progressive ventricular dysfunction and dilatation
Acute Exacerbations Contribute to the Progression
of the Disease
The ADHERE Registry• ADHERE (Acute Decompensated HEart Failure
National REgistry) was a prospective, observational database of patients hospitalized with acutely decompensated heart failure
• Over 275 US hospitals participated in this project, including community, tertiary, and academic medical centers
• More than 200,000 patients were enrolled in ADHERE
Characteristics of Heart Failure Patients Enrolled in the
ADHERE Registry• Average age: 72.5 years
• Women: 52%
• Ischemic etiology (CAD): 60%
• Renal insufficiency: 30%
• Preserved LV systolic function: ≈50%
• Atrial fibrillation: 31%
• Diabetes: 44%
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• High proportion (50%) of patients with congestive heart failure have normal LV systolic function
• Variably called diastolic heart failure (DHF), heart failure with preserved ejection fraction (HFPEF), and heart failure with normal ejection fraction (HFNEF)
Heart Failure with a NormalEjection Fraction
• Hospital admission rates for patients with diastolic heart failure are similar to systolic heart failure
• There is no gold standard for diagnosis of DHF and no standardized treatment
Heart Failure with a NormalEjection Fraction
1.Signs and symptoms of CHF
2.Normal LV ejection fraction
3.Measurement of diastolic function is confirmatory but not mandatory
Coronary revascularization is reasonable in patients with HF and normal LVEF and coronary artery disease in whom symptomatic or demonstrable myocardial ischemia is judged to be having an adverse effect on cardiac function.
The use of beta-adrenergic blocking agents, ACEIs, ARBs, or calcium antagonists in patients with HF and normal LVEF and controlled hypertension might be effective to minimize symptoms of HF.
The use of beta-adrenergic blocking agents, ACEIs, ARBs, or calcium antagonists in patients with HF and normal LVEF and controlled hypertension might be effective to minimize symptoms of HF.
The use of beta-adrenergic blocking agents, ACEIs, ARBs, or calcium antagonists in patients with HF and normal LVEF and controlled hypertension might be effective to minimize symptoms of HF.
• RV Systolic Pressure• RV Diastolic Pressure• Estimated PA Diastolic Pressure• Other Parameters
IHM Home Monitor Clinician access
Secure Network
RV Pressure Monitor:Correlation to Swan Ganz
0 20 40 60 80 100 120
Swan-Ganz RV Systolic Pressure (mmHg)
020
4060
8010
012
0
Chr
onic
le R
V Sy
stol
ic P
ress
ure
(mm
Hg)
Systolic
r = 0.95
0 20 40 60
Swan-Ganz RV Diastolic Pressure (mmHg)
020
4060
Chr
onic
le R
V D
iast
olic
Pre
ssur
e (m
mH
g)
Diastolic
r = 0.87
0 20 40 60 80
Swan-Ganz PAD Pressure (mmHg)
020
4060
80
Chr
onic
le P
AD
Pre
ssur
e (m
mH
g)
ePAD
r = 0.84
Magalski, A, et al. Continuous Ambulatory Right Heart Pressure Measurements with an Implantable Hemodynamic Monitor: a Multi-center, 12 Month Follow-up Study of Patients with Chronic Heart Failure, J Card Failure. 2002;8(2):63-70.
COMPASS- HF Trial:Primary Endpoint
11384Total HF-Related Events
9972Hospitalizations
1110Emergency Dept Visits
0.850.67Event Rate / 6 months
21%% Reduction in Event Rate
6044# of Pts with Events
Urgent Clinic Visits 32
CONTROL(n=140)
CHRONICLE(n=134)
p=0.33
Cumulative Events
0
20
40
60
80
100
120
Even
ts
CHRONICLE
CONTROL
642Months
0
• Un-powered, implantable wireless pressure sensor• Implanted in the distal pulmonary artery• Pressure measurements performed at home or in
the physicians office using simple RF based electronics
• Pressure data automatically forwarded to physician, can be viewed on custom website portal
PA Pressure Sensor
Home Monitoring Unit Sensor
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PA Sensor vs Swan Ganz
Regression Plot of Sensor vs. SG Mean Pressure Measurements for 16 Patients
R2 = 0.961
0102030405060708090
100
0 20 40 60 80 100
SG reading (mm Hg)
Sen
sor r
eadi
ng (m
m H
g)
Implantable LA Pressure Monitor
Implantable Communications Module (ICM)
Lead
Sensor Module
Proximal Anchor
Distal Anchor
Sensor Diaphragm
~ 3 mm
Measures•LAP•IEGM•Core Temp
Implantable Sensor Lead (ISL)
LAP Accuracy VS. PCWP
LAP = 0.94xPCWP + 2.0R2 = 0.95
n=429
0
20
40
60
80
100
0 20 40 60 80 100
PCWP (mmHg)
LAP
(mm
Hg)
NTGRestProvocationValsalva
-50
-30
-10
10
30
50
0 20 40 60 80 100Mean of LAP and PCWP (mmHg)
LAP
-PC
WP
(mm
Hg)
mean = 0.5 mmHg±2 SD = 9.0 mmHg
n=429
Patient Management Using the LAP
Monitoring SystemPatient obtains LAP readings twice a day with PAM at rest & supine prior to meds