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. Management of Heart Failure with Preserved Ejection Fraction Ivan Anderson, MD RIHVH Cardiology .
. Outline • Review: • What Heart Failure is and is Not • Classification schema for CHF • Disease mechanisms and phenotypes • Medical management of stable/ compensated Heart Failure with Preserved Ejection Fraction (HFpEF) .
. Outline • Review: • What Heart Failure is and is Not • Classification schema for CHF • Disease mechanisms and phenotypes • Medical management of stable/ compensated Heart Failure with Preserved Ejection Fraction (HFpEF) .
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. Causes for Elevated Natriuretic Peptide Levels Non-cardiac • Advancing age • Anemia • Renal failure • Pulmonary causes: obstructive sleep apnea, severe pneumonia, pulmonary hypertension • Critical illness • Bacterial sepsis • Severe burns • Toxic-metabolic insults, including cancer chemotherapy and envenomation .
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. Outline • Review: • What Heart Failure is and is Not • Classification schema for CHF • Disease mechanisms and phenotypes • Medical management of stable/ compensated Heart Failure with Preserved Ejection Fraction (HFpEF) .
. Outline • Review: • What Heart Failure is and is Not • Classification schema for CHF • Disease mechanisms and phenotypes • Medical management of stable/ compensated Heart Failure with Preserved Ejection Fraction (HFpEF) .
. Classification of Heart Failure ACCF/AHA Stages of HF NYHA Functional Classification A At high risk for HF but without structural None heart disease or symptoms of HF. B Structural heart disease but without signs I No limitation of physical activity. or symptoms of HF. Ordinary physical activity does not cause symptoms of HF. C Structural heart disease with prior or I No limitation of physical activity. current symptoms of HF. Ordinary physical activity does not cause symptoms of HF. II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF. III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF. IV Unable to carry on any physical activity D Refractory HF requiring specialized without symptoms of HF, or symptoms of interventions. HF at rest. .
. 2 Flights of Stairs .
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. Early Atrial Filling (E wave) Late Atrial Filling from atrial contraction (A wave) .
. Outline • Review: • What Heart Failure is and is Not • Classification schema for CHF • Disease mechanisms and phenotypes • Medical management of stable/ compensated Heart Failure with Preserved Ejection Fraction (HFpEF) .
. Outline • Review: • What Heart Failure is and is Not • Classification schema for CHF • Disease mechanisms and phenotypes • Medical management of stable/ compensated Heart Failure with Preserved Ejection Fraction (HFpEF) .
. Echocardiography should not be used as a “tie breaker” to diagnose Heart Failure .
. LV RV LA RA Apical 4 Chamber View .
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. 1. Myopathic process in the left ventricle 2. Left atrial 4 hypertension 2, 3 3. Left atrial enlargement 1 4. Pulmonary venous hypertension .
. Risk Scoring I IIa IIb III Validated multivariable risk scores can be useful to estimate subsequent risk of mortality in ambulatory or hospitalized patients with HF. .
. Risk Scores to Predict Outcomes in HF Risk Score Reference (from full-text guideline)/Link Chronic HF All patients with chronic HF Seattle Heart Failure Model (204) / http://SeattleHeartFailureModel.org Heart Failure Survival Score (200) / http://handheld.softpedia.com/get/Health/Calculator/HFSS-Calc- 37354.shtml CHARM Risk Score (207) CORONA Risk Score (208) Specific to chronic HFpEF I-PRESERVE Score (202) Acutely Decompensated HF ADHERE Classification and Regression (201) Tree (CART) Model American Heart Association Get With the (206) / http://www.heart.org/HEARTORG/HealthcareProfessional/GetWithTheGuidel Guidelines Score inesHFStroke/GetWithTheGuidelinesHeartFailureHomePage/Get-With-The- Guidelines-Heart-Failure-Home- %20Page_UCM_306087_SubHomePage.jsp EFFECT Risk Score (203) / http://www.ccort.ca/Research/CHFRiskModel.aspx ESCAPE Risk Model and Discharge Score (215) OPTIMIZE HF Risk-Prediction Nomogram (216) .
. Treatment of HF p EF Recommendations COR LOE Systolic and diastolic blood pressure should be controlled I B according to published clinical practice guidelines Diuretics should be used for relief of symptoms due to I C volume overload Coronary revascularization for patients with CAD in IIa whom angina or demonstrable myocardial ischemia is 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 IIa C for hypertension in HFpEF ARBs might be considered to decrease hospitalizations in IIb B HFpEF Nutritional supplementation is not recommended in III: No C HFpEF Benefit .
. Pharmacological Treatment for Stage C HF p EF I IIa IIb III Systolic and diastolic blood pressure should be controlled in patients with HF p EF in accordance with published clinical practice guidelines to prevent morbidity. I IIa IIb III Diuretics should be used for relief of symptoms due to volume overload in patients with HF p EF. Coronary revascularization is reasonable in patients with I IIa IIb III CAD in whom symptoms (angina) or demonstrable myocardial ischemia is judged to be having an adverse effect on symptomatic HF p EF despite GDMT. .
. Pharmacological Treatment for Stage C HF p EF (cont.) I IIa IIb III Management of AF according to published clinical practice guidelines in patients with HF p EF is reasonable to improve symptomatic HF. I IIa IIb III The use of beta-blocking agents, ACE inhibitors, and ARBs in patients with hypertension is reasonable to control blood pressure in patients with HF p EF. .
. Pharmacological Treatment for Stage C HF p EF (cont.) I IIa IIb III The use of ARBs might be considered to decrease hospitalizations for patients with HF p EF. I IIa IIb III Routine use of nutritional supplements is not recommended for patients with HF p EF. No Benefit .
. Mana nage Com e Comorbidities es .
. Questions/Comments? .
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