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Heart Failure With Preserved Ejection Fraction

The document discusses heart failure with preserved ejection fraction (HFpEF). Key points include: 1. HFpEF is characterized by signs of pulmonary congestion despite normal cardiac output at rest and impaired cardiac output reserve during exercise due to chronotropic incompetence. 2. The diagnosis of HFpEF is challenging as there is no validated gold standard, especially in elderly patients with comorbidities and no obvious signs of fluid overload. 3. Currently, medications shown to improve outcomes in heart failure with reduced ejection fraction have not been proven effective for HFpEF. Treatment focuses on diuretics, managing comorbidities, and exercise training.

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Mega Almira
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106 views

Heart Failure With Preserved Ejection Fraction

The document discusses heart failure with preserved ejection fraction (HFpEF). Key points include: 1. HFpEF is characterized by signs of pulmonary congestion despite normal cardiac output at rest and impaired cardiac output reserve during exercise due to chronotropic incompetence. 2. The diagnosis of HFpEF is challenging as there is no validated gold standard, especially in elderly patients with comorbidities and no obvious signs of fluid overload. 3. Currently, medications shown to improve outcomes in heart failure with reduced ejection fraction have not been proven effective for HFpEF. Treatment focuses on diuretics, managing comorbidities, and exercise training.

Uploaded by

Mega Almira
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Heart Failure with Preserved

Ejection Fraction (HFpEF)

Erwinanto MD

The Indonesian Heart Association Working

Group on Heart Failure


HFpEF: What’s in a Name?
Evidence of pulmonary congestion despite
normal cardiac output at rest

Control HFpEF
Resting hemodynamic P-value
(n=73) (n=109)

Cardiac output (L/min) 5.4 ± 1.4 5.4 ± 1.7 0.9

Cardiac index (L/min/m2) 2.8 ± 0.7 2.6 ± 0.8 0.2

PCWP (mmHg) 9±3 16 ± 6 <0.0001

Abudiab MM, et al. Eur J Heart Fail 2013;15:776-785


FORRESTER CLASSIFICATION
3.5
Normal
3
HFpEF
2.5 H-I H-II
CI (L/m/m2)

C-I C-II
2.2
Hypoperfusion

2 H-III H-IV
C-III C-IV
1.5 Fluid administration

Mortality 22.4% HFrEF


1

Hypovolemic shock
0.5
0 5 10 15 20 25 30 35 40
18
PCWP (mm Hg)

Hypovolemia Pulmonary congestion

Adapted from Forester et al. Am J Cardiol 1977;39:137


Impaired cardiac output reserve

Control HFpEF
Peak exercise hemodynamic P-value
(n=73) (n=109)

Cardiac output (L/min) 12.5 ± 2.8 9.2 ± 2.8 <0.0001

Cardiac index (L/min/m2) 6.4 ± 1.3 4.4 ± 1.2 <0.0001

PCWP (mmHg) 14 ± 4 33 ± 8 <0.0001

Abudiab MM, et al. Eur J Heart Fail 2013;15:776-785


Chronotropic incompetence causes
impaired cardiac output reserve

Abudiab MM, et al. Eur J Heart Fail 2013;15:776-785


Less increase of EF during exercise

Ejection fraction (%)

At rest P-value

Control 63 ± 8
0.09
HFpEF 65 ± 7

Abudiab MM, et al. Eur J Heart Fail 2013;15:776-785


Afterload

Katup aorta
menutup
Katup aorta
Ejeksi terbuka
Tekanan ventrikel

Relaksasi Kontraksi

Preload

Katup mitral Pengisian


terbuka Katup mitral
menutup

Volume ventrikel
Resting LV Pressure-Volume Loops in Systolic and
Diastolic Dysfunction

Afterload

Normal Increased Normal Normal

Preload

Aurigemma GP, Gaasch WH. N Engl J Med 2004;351:1097-1105


Mechanism of HFpEF
Molecular Basis of Heart Failure

Myocardial injury

↑myocyte size
Activation of Hypertrophic
signaling pathways response
↑extra cellular
matrix

Impaired myocyte function


Heart failure
Myocyte loss
Sharma K, Kass DA. Circ Res. 2014;115:79-96
Sharma K, Kass DA. Circ Res. 2014;115:79-96
Diagnosis of HFpEF
Terminology of heart failure with preserved (HFpEF), mid-range (HFmrEF)

and reduced ejection fraction (HFrEF)

Type of HF HFrEF HFmrEF HFpEF

1 Symptoms ± signs Symptoms ± signs Symptoms ± signs

2 LVEF ˂40% LVEF 40-49% LVEF ≥50%


CRITERIA

1. ↑Natriuretic peptide 1. ↑Natriuretic peptide

2. At least 1 additional 2. At least 1 additional


3 ̶
criterion: criterion:
a) LVH and/or LAE a) LVH and/or LAE
b) diastolic dysfunction b) diastolic dysfunction

LVEF = left ventricular ejection fraction; LVH = left ventricular hypertrophy; LAE = left atrial enlargement

Ponikowski P, et al. Eur Heart J doi:10.1093/eurheartj/ehw128


• May be higher in AF and elderly without heart failure
• May be normal in obese patients with HFpEF

Ponikowski P, et al. Eur Heart J doi:10.1093/eurheartj/ehw128


Bishu K, et al. Am Heart J 2012; 164:763-770
Key structural and functional alteration in HFpEF

Left atrial volume index (LAVI)* ˃ 34 mL/m2

≥ 115 g/m2 (males)


Left ventricular mass index (LVMI)
≥ 95 g/m2 (females)

E/é ≥ 13

Mean é septal and lateral wall < 9 cm/s

*LAVI is increased by AF

Ponikowski P, et al. Eur Heart J doi:10.1093/eurheartj/ehw128


Invasive hemodynamics at rest

Pulmonary capillary wedge pressure


≥ 15 mm Hg
(PCWP)

Left ventricular end diastolic pressure


≥ 16 mm Hg
(LVEDP)

Ponikowski P, et al. Eur Heart J doi:10.1093/eurheartj/ehw128


Treatment of HFpEF
Clinicians should recommend a

daily target of 30 minutes of

aerobic exercise.

Redfield MM. N Engl J Med 2016;375:1868-77.


Drug treatment effects on outcomes in HFpEF:
a systematic review and meta-analysis

Zheng SL, et al. Heart 2017;0:1–9. doi:10.1136/heartjnl-2017-311652


Solomon SD, et al. J Am Coll Cardiol HF 2017;5:471–82

PARAGON-HF will determine whether sacubitril/valsartan

is superior to angiotensin receptor blockade alone in

patients with chronic symptomatic HFpEF.


Recommendations for treatment of patients with HFpEF

Ponikowski P, et al. Eur Heart J doi:10.1093/eurheartj/ehw128


Clinical
Phenotypes
and
Comorbid
Conditions
of HFpEF

Samson R, et al.
J Am Heart Assoc 2016
doi: 10.1161/JAHA.115.002477
Take-home message
• Heart failure with preserved ejection fraction remains

among the most challenging of clinical syndromes for

the practicing clinician and scientist alike.

• The diagnosis of chronic HFpEF, especially in the

typical elderly patient with co-morbidities and no

obvious signs of central fluid overload, is

cumbersome and a validated gold standard is

missing.
• Medications that improve outcomes in patients who
have heart failure with a reduced ejection fraction
have not been shown to be of benefit in those who
have heart failure with a preserved ejection fraction.

• Treatment of heart failure with a preserved ejection


fraction should include diuretics for volume
overload, treatment for cardiovascular and
noncardiovascular coexisting conditions, and
aerobic exercise training to increase exercise
tolerance.

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