HFpEF: what is it & size of the problem? Adriaan Voors, - - PowerPoint PPT Presentation

HFpEF:

what is it & size of the problem?

Adriaan Voors, University Medical Center Groningen

History of HFpEF

• 1992 a review paper entitled ”diastolic heart failure” was published by Pravin

Shah and Ramdas Pai.

• A few quotes:
• “Diastolic heart failure is a distinct clinical entity increasingly seen in older patients and requires special

awareness to make the diagnosis”

• “It appears that prognosis is significantly better for those with normal systolic function.”
• “Diastolic heart failure is difficult to treat.”

Is HFpEF “real” HF? 1995 European Society Guidelines for diagnosis of HF:

“Conclusive evidence that most elderly patients with a diagnostic label of heart failure but with normal systolic function at rest do indeed have heart failure is lacking.”

Bursi et al. JAMA 2006

HFrEF = diastolic dysfunction

Distribution of Ejection Fraction and Diastolic Dysfunction Among Patients with Heart Failure

*Mild diastolic function represents impaired relaxation mitral inflow patterns with normal filling pressures; moderate diastolic dysfunction represents impaired relaxation mitral inflow patterns with elevated filling pressures or a pseudo normal mitral inflow pattern with elevation of filling pressures; and severe diastolic dysfunction represents restrictive mitral inflow patterns ** Patients with isolated diastolic dysfunction

HFpEF = systolic dysfunction

Average Longitudinal and Circumferential Systolic Strain

Average longitudinal and circumferential systolic strain among normal controls, HHD, HFpEF patients, and in 3 categories HFpEF based on LVEF

* P <0.0001 compared to controls and between HHD and HFpEF overall for longitudinal strain and circumferential strain # P – 0.0002 compared to controls † LVEF-adjusted p < 0.001 compared to controls HFpEF – Heart Failure with Preserved Ejection Fraction HHD – Hypertensive Heart Disease LVEF – Left Ventricular Ejection Fraction 0%

• 5%
• 10%
• 15%
• 20%
• 25%
• 30%

Controls

(n=50)

HHD

(n=44)

HFpEF overall

(n=219)

LVEF

50-55%

LVEF

45-50%

LVEF

>55%

Longitudinal Circumferential HFpEF

“Other phrases have been used to describe diastolic HF, such as HF with preserved ejection fraction (HFPEF), HF with normal ejection fraction (HFNEF), or HF with preserved systolic function (HFPSF). We have elected to use the abbreviation HFPEF in this document.”

Prevalence of HFpEF

HFpEF Prevalence

Hogg et al, JACC, 2004, Owan et al, Prog Cardiovas Dis, 2005 Owan et al, NEJM, 2006; Bursi F et al, JAMA, 2006

13 Community Based Studies 1997- 2006

100% 80% 60% 40% 20% 0%

Median = 52% Mean = 55%

Oktay, Rich, Shah Curr Heart Fail Rep 2013

Trends in HFpEF prevalence

60% 50% 40% 30% 20% 10% 0%

Proportion of Hospitalized Heart Failure Patients

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

year

~

EF > 50%

~ EF < 40% ~ EF > 40-50%

Age: HFpEF > HFrEF Females: HFpEF > HFrEF Hypertension: HFpEF > HFrEF Obesity: HFpEF ≥ HFrEF Diabetes: HFpEF ≥ HFrEF CAD: HFpEF < HFrEF

Lam et al Eur J Heart Fail 2011

Patient with HFpEF are different from HFrEF

Streng et al. Int J Cardiol 2018

Prevalence of non-cardiac comorbidities in Heart Failure groups

Diabetes Thyroid dysfunction Stroke COPD CKD Anaemia Obesity PAD 60% 50% 40% 30% 20% 10% 0%

Diabetes,Obesity, Hypertension Endothelial Dysfunction

Oxidative Stress, NO-cGMP-PKG Inflammation, EndMT, Fibroblast Activation

Tschope and Lam Herz 2012

Titin changes Fibrosis

Pathophysiology of HFpEF

Diastolic Dysfunction

Campbell J Am Coll Cardiol 2012

HFpEF: More than comorbidities

Cardiovascular and HFpEF Trials:

11.4 15.7 16.4 17.3 25.6 28.7 47.2 53 54 76

80 70 60 50 40 30 20 10

Per 1000 patient years

Overall Mortality

Cardiovascular Trials HFpEF Trials

Campbell J Am Coll Cardiol 2012

HFpEF: More than comorbidities

4.6 5.3 5.5 7.1 7.5 11 11.5 43 69 73

80 70 60 50 40 30 20 10

Per 1000 patient years

Cardiovascular and HFpEF Trials:

Heart Failure Hospitalization

Cardiovascular Trials HFpEF Trials

• Often co-exist
• AF makes diagnosis of HFpEF even more difficult
• Share same risk factors
• Share same pathophyisology
• AF might cause HFpEF and HFpEF might cause AF

HFpEF and AF

Bhatia et al Owan et al Smith et al Philbin et al 50% 40% 30% 20% 10% 0% Mortality

Prognosis of Diastolic Heart Failure

Annualized mortality in patients hospitalized for DHF versus SHF

Mortality estimates have been adjusted to reflect annual mortality DHF

Diastolic Heart Failure

SHF

Systolic Heart Failure

Shah P.M. et al, Current Problems in Cardiology,1992

Owan et al. NEJM 2006

Prognosis of HFpEF

1.0 0.8 0.6 0.4 0.2 0.0

Survival

1 2 3 4 5

Reduced EF 2424 1637 1350 1049 813 604 Preserved EF 2166 1539 1270 1001 758 574

• No. At Risk

Reduced Ejection Fraction Preserved Ejection Fraction

P=0.03 Year Survival Curves for Patients with Heart Failure and Preserved or Reduced Ejection Fraction

Bhatia et al. NEJM 2006

Prognosis of HFpEF

Adjusted Survival Curves for Patients with Heart Failure with Reduced or Preserved Ejection Fraction over the Year after the First Hospital Admission.

100% 95% 90% 85% 80% 75% 70% 0% 50 100 150 200 250 300 350 400

Days Survival

Preserved Ejection Fraction Reduced Ejection Fraction

Bhatia et al. NEJM 2006

Prognosis of HFpEF

In-Hospital care, Complications , and Outcomes:

* Readmission rates were calculated for the 2339 patients who survived the index admission: 1493 with reduced ejection fraction and 846 with preserved ejection fraction

Treatment of HFpEF

No treatment has yet been shown, convincingly, to reduce morbidity or mortality in patients with HFpEF

ESC Heart Failure Guidelines EJHF 2008 +2012+2016

Conclusions

• HFpEF is (increasingly) prevalent
• Related to high mortality and morbidity
• Difficult to diagnose
• Heterogeneous with many co-morbidities
• Difficult to understand pathophysiology
• Difficult to treat