SLIDE 1 Burkert Pieske M.D. Berlin, Germany
HFpEF: How to optimise management
Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité University Medicine Berlin, and Department of Internal Medicine and Cardiology, German Heart Center, Berlin, Germany
SLIDE 2
Disclosures
Speaker Bureau, Consultancy, Advisory Board/Committee for: Bayer Healthcare, MSD, Novartis, Astra-Zeneca, Stealth Peptides, Servier, Daiichi- Sankyo, Biotronic, Abbott Vascular
SLIDE 3 ESC 2016: How to optimize management
- 1. Identify the patient – Diagnosis
- 2. Classify the patient – Etiology and Stratification
- 3. General principles of management
- 4. Specific therapeutic approaches
SLIDE 4
ESC 2016: Typical demographics and co-morbidities associated with HFpEF – Who are these patients?
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ESC HF GL 2016: Definition of heart failure with preserved (HFpEF), mid-range (HFmrEF) and reduced ejection fraction (HFrEF)
ESC 2016: „Signs and symptoms of HF are often non-specific and do not discriminate well between HF and other clinical conditions“
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Diagnostic algorithm for HF of non-acute onset
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ESC 2016 Key Diagnostic HFpEF Criteria
„Preserved“ EF ≥ 50% Structural alterations: LAVI >34 mL/m2 or LVMI ≥ 115 (males) / ≥95 (females) mg/m2 Functional alterations: E/é ≥ 13 é (mean septal and lateral) <9 cm/s NTproBNP: >125 pg/mL or (SR; increase with Afib!) BNP: >35 pg/mL
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ESC 2016: Normal & abnormal echocardiographic indices of diastolic function according to age categories, differentiated for gender
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ESC 2016 Additional Diagnostic HFpEF Criteria
Longitudinal strain Tricuspid regurgitation velocity Diastolic stress test: Semi-supine exercise echocrdiography Invasive hemodynamics at rest (PCWP≥15 mmHg) and with exercise
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Exercise echocardiography (Diastolic stress test)
SLIDE 11 ESC 2016: How to optimize management
- 1. Identify the patient – Diagnosis
- 2. Classify the patient – Etiology and Stratification
- 3. General principles of management
- 4. Specific therapeutic approaches
SLIDE 12 Senni & Pieske, Eur Heart J 2014
SLIDE 13 Prospective cross-sectional study, symptomatic HFpEF including LVH (LVEDWT ≥12mm)
99mTc-3,3-diphosphono-1,2-propanodi-carboxylic acid scintigraphy (99mTc-DPD)
Genetic analysis for mutations in the TTR gene
SLIDE 14 Gonzáles-López E et al. Eur Herat J 2015; 36:2585-2594
99mTc-3,3-diphosphono-1,2-propanodi-carboxylic acid
scintigraphy (severe 99mTc-DPD cardiac uptake)
Wild-type transthyretrin amyloidosis: Scintigraphy
SLIDE 15 Summary: Diagnosis of HFpEF
- 120 HFpEF patients included
- 16 patients (13.3%) with moderate-severe 99mTc-DPD
cardiac uptake
- No mutations found on genetic testing
- EMB in 4 patients demonstrated ATTR WT in all cases
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ESC 2016: Diagnostic tests for specific causes of HFpEF
SLIDE 17 ESC 2016: How to optimize management
- 1. Identify the patient – Diagnosis
- 2. Classify the patient – Etiology and Stratification
- 3. General principles of management
- 4. Specific therapeutic approaches
SLIDE 18 ESC 2016: How to optimize management
- Only slightly fewer patients with HFpEF appear to receive diuretics,
beta-blockers, MRAs, ACEI, or ARBs - comorbidities or extrapolation?
- Screen and treat cardiovascular comorbidities – Arterial hypertension,
CAD, pulmonary hypertension
- Screen and treat non-cardiovascular comorbidities (diabetes, CKD,
anaemia, iron deficiency, COPD, obesity)
- Hospitalisations/death in HFpEF more likely to be non-cardiovascular
than in HFrEF
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Importance of co-morbidities in patients with HF
SLIDE 20
Recommendations for treatment of patients with HFpEF and HFmrEF
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ESC 2016: Management of specific comorbidities
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Treatments not recommended for co-morbidities in patients with HF
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General principles of management
1.Optimal control of risk factors and comorbidities? BP<130/80 mmHg (preferentially by RAS blocker) HBA1c < 6.5 mg% (Metformin, SGL2-Inhibitor; avoid insulin wherever possible) Statin therapy in indicated Correct myocardial ischemia Treat pulmonary disease 2.Inadequate hypertensive blood pressure response to exercise? Stress test – optimize BP response 3.Heart rate response to exercise? Tachycardic – control inadequate increases in heart rate Chronotropic incompetence? Reduce bradycardic agents, consider PM
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General principles of management
4.Atrial fibrillation? Restore SR if possible Anticoagulation as indicated 5.Signs of hypervolemia or pulmonary congestion? Loop diuretics Restrict volume and salt intake 6.Physical inactivity/overweight? Implement physical activity/exercise training programs Initate weight loss preferably by structured programs
SLIDE 25 Targeting therapies to the HFpEF phenotype
Senni M & Pieske B, Eur Heart J 2014
SLIDE 26 ESC 2016: How to optimize management
- 1. Identify the patient – Diagnosis
- 2. Classify the patient – Etiology and Stratification
- 3. General principles of management
- 4. Specific therapeutic approaches
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SLIDE 28
ESC 2016: Specific HFpEF therapies?
ESC 2016: „No treatment has been shown, convincingly, to reduce morbiditiy and mortality in patients with HFpEF or HFmrEF“
SLIDE 29 Mitter SS and Shah SJ., Curr Atheroscler Rep, 2015 Nov, 17(11):64
SLIDE 30 Total HF Hosp Spiro : 394 Placebo: 475 P<0.01*
*poisson regression 245/1723 (14.2%) 206/1722 (12.0%)
TOPCAT: Heart Failure Hospitalizations TOPCAT: Heart Failure Hospitalizations
Spironolactone Placebo HR = 0.83 (0.69 – 0.99) p=0.042
SLIDE 31 Suggested algorithm for Sprinolactone in HFpEF
Mitter SS and Shah SJ., Curr Atheroscler Rep, 2015 Nov, 17(11):64
SLIDE 32 Hasenfuss G et al., J Card Fail, 2015 Jul, 21(7):594-600
Generation of an inter-atrial shunt
SLIDE 33 Hasenfuß Lancet 2016
SLIDE 34 Kitzman DW et al., JAMA, 2016 Jan 5, 315(1):36-46
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SLIDE 36 Ex-DHF pilot: Exercise training in elderly HFpEF
Primary Endpoint: peak VO2 Maximum Workload
Edelmann F et al., JACC 2011;58:1780–91 HFpEF=heart failure with preserved ejection fraction
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- New definitions: HFpEF vs. HFmrEF, more specific imaging cutoffs
- Exercise stress test (echo, invasive, mentioned for first time)
- Mandates for etiological workup to target therapies
- Mandates for minute assessment and therapy of comorbidities
- Give general management recommendations, including loop diuretics
- State that no specific therapies are available yet
Summary: ESC 2016 – Management of HFpEF
