HFrEF vs HFpEF reduced EF vs preserved EF · HFpEF (YLGHQFHGRHVQ¶WVXSS RUWXVHRIWULSOHWKHUDS\ Diuretics remain cornerstone of therapy Optimising treatment of co-morbidities Ongoing

HFrEF vs HFpEF

reduced EF vs preserved EF

Heart Failure ECHO Clinic

Virtual Heart Failure Consultation and Education

Prof Ken McDonald & Dr. Patricia Campbell

xth January 2017

• ‘HF is a clinical syndrome characterised by • typical symptoms +/- signs

• caused by a structural or functional cardiac abnormality

• that results in ↓ cardiac output and/or ↑ intracardiac pressures’

• HF with reduced ejection fraction (HFrEF)

• EF < 40%

• HF with preserved ejection fraction (HFpEF)

• EF > 40%

Definition

• HF-MREF new category and falls into the HF-PEF classification

• Unknown entity, ignore for now

Latest Guidelines

ESC HF Guidelines 2016. Eur J Heart Fail. 2016 Aug;18(8):891-975

• HFrEF

• Younger

• Ischaemia

• Inherited and acquired cardiomyopathies

• HFpEF

• Older

• Female

• Multiple co-morbidities (HTN, T2DM, renal impairment)

Population

HFrEF

Triple therapy with ACEi/ARB, B blocker and MRA

ARNI (Sacubitril/Valsartan)

Ivabradine/nitrates/digoxin

ICD +/- CRT

HFpEF

Evidence doesn’t support use of triple therapy

Diuretics remain cornerstone of therapy

Optimising treatment of co-morbidities

Ongoing studies to assess ARNI in HF-PEF population

Differences in treatment

HF activates 3 neurohormonal systems

Levin et al. N Engl J Med 1998;339:321–8 Nathisuwan & Talbert. Pharmacotherapy 2002;22:27–42 Kemp & Conte. Cardiovascular Pathology 2012;365–71 Schrier & Abraham. N Engl J Med 2009;341:577–85

Sympathetic

nervous system

Renin-angiotensin-

aldosterone system

Vasoconstriction Blood pressure

Sympathetic tone Aldosterone Hypertrophy

Fibrosis

Ang II AT1R

HF SYMPTOMS &

PROGRESSION

Natriuretic peptide

system

Vasodilation Blood pressure Sympathetic tone Natriuresis/diuresis Vasopressin Aldosterone Fibrosis Hypertrophy

NPRs NPs

Epinephrine

Norepinephrine α1, β1, β2

receptors

Vasoconstriction RAAS activity

Vasopressin Heart rate

Contractility

HFrEF – Triple Therapy Standard

ESC HF Guidelines 2016. Eur J Heart Fail. 2016 Aug;18(8):891-975

LCZ696: enhancement of natriuretic and other vasoactive peptides, with simultaneous RAAS suppression

Evolution of therapy in HF: Sacubitril/Valsartan as a new alternative to an ACEI or ARBs in patients with HFrEF1

1. McMurray et al. Eur J Heart Fail 2013;15:1062–73

Figure references:

Levin et al. N Engl J Med 1998;339:321–8

Nathisuwan & Talbert. Pharmacotherapy 2002;22:27–42 Kemp & Conte. Cardiovascular Pathology 2012;365–71 Schrier & Abraham. N Engl J Med 2009;341:577–85

Vasoconstriction Blood pressure

Sympathetic tone Aldosterone Hypertrophy

Fibrosis

Ang II AT1R

HF SYMPTOMS &

PROGRESSION

INACTIVE FRAGMENTS

Vasodilation Blood pressure Sympathetic tone Natriuresis/diuresis Vasopressin Aldosterone Fibrosis Hypertrophy

NPRs NPs

Epinephrine

Norepinephrine α1, β1, β2

receptors

Vasoconstriction RAAS activity

Vasopressin Heart rate

Contractility

SNS β-blockers

RAAS RAAS inhibitors

(ACEI, ARB, MRA)

NP system

Neprilysin inhibitors

LCZ696

Further RAAS adjustments if ongoing issues

ESC HF Guidelines 2016. Eur J Heart Fail. 2016 Aug;18(8):891-975

HF-PEF recommendations

ESC HF Guidelines 2016. Eur J Heart Fail. 2016 Aug;18(8):891-975

Different populations

Different therapies

Different reasons for

hospitalisation

Similar mortality

outcomes and

hospitalisation rates

Outcomes: HF-REF vs HF-PEF

Rajdip Dulai et al. Br J Cardiol 2016;23

P = 0.551

To apply for the CME Certification:

Return signed CME form to:

Ms Rosemary Geoghegan

Fax: 01-2713070

E-mail: [email protected]

Thank you for your participation