Scompenso Cardiaco con frazione di eiezione preservata
Dott.ssa C.RaineriDivisione di Cardiologia, Fondazione IRCCS Policlinico S.Matteo, Pavia
ESC GUIDELINES European Heart Journal (2016) 37, 2129–2200
Definition of HFpEF
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
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
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
The American Journal of Medicine 2016; 129: 635.e15-635.e26
Non cardiac co-morbidities in Patients Hospitalized with HFpEF
The American Journal of Medicine 2016; 129: 635.e15-635.e26
Cardiovascular disease in pts with HFpEF vs HFrEF
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.
Hwang et al. J Am Coll Cardiol 2014;63:2817–27
Impact of CAD on Survival in Patients With HFpEF
Redfield. N Engl J Med 2016;375:1868-77
Pathophysiological Model of HFpEF
Obokata et al. J Am Coll Cardiol 2019
Pathophysiologic contributors to HFpEF
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
Borlaug et al Circ J 2014; 78: 20–32
HFpEF: ↑ PCWP/LVEDP and PAP with exercise
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
Chronotropic incompetence in HFpEF
Borlaug et al Circ J 2014; 78: 20–32
Myocardial Reserve Dysfunction in HFpEF
Circ Heart Fail. 2019;12:e006240
Kawaguchi et al. Circulation. 2003;107:714-720
A-V couplingin HFpEF
Arterial elastance (Ea) and Ees are elevated in tandem in HFpEF
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
• 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
Pulmonary Hypertension and Outcomes in HFpEF
JAMA Cardiol. 2018;3(4):298-306
Elevated PVR Are Associated With Increased Mortalityin the PH-HFpEF Cohort
JAMA Cardiol. 2018;3(4):298-306
RV dysfunction in HFpEF
Melenovsky et al. Eur Heart J 2014;35: 3452–3462
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
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.
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
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 )
Causes of Death Across Age Strata
J Am Coll Cardiol 2019;74:601–12
Eur Heart J 2019; 40, 3297–3317
Eur Heart J 2019; 40, 3297–3317
Diagnostic Workup and Scoring System
Eur Heart J 2019; 40, 3297–3317
Advanced work-up: Echo stress test
Eur Heart J 2019; 40, 3297–3317
Advanced work-up:invasive haemodynamic Measurments
Eur Heart J 2019; 40, 3297–3317
Aetiological work-up
Chamsi-Pasha JACC Cardiovasc Imaging 2019
CMR in the Evaluation of Diastolic Dysfunction and Phenotyping of HFpEF
CMR and HFpEF
Treatment of HFpEF
TOPCAT
Outcome trials in HFpEF
Clealand et al. Heart Fail Clinics 2014;10:511-523
Angiotensin–Neprilysin Inhibition in HFpEFParagon-HF trial
N Engl J Med 2019;381:1609-20
Curr Treat Options Cardio Med 2019; 21: 20
In the absence of convincingtrial data, what should we do?
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
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
Schwartzenberg, et al. J Am Coll Cardiol 2012;59:442–51
Need to be careful with vasodilators...
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