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Management of Heart Failure with Preserved

Ejection Fraction

Ivan Anderson, MDRIHVH Cardiology

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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 Failurewith Preserved Ejection Fraction (HFpEF)

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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)

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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)

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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)

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Classification of Heart FailureACCF/AHA Stages of HF NYHA Functional Classification

A At high risk for HF but without structural heart disease or symptoms of HF.

None

B Structural heart disease but without signs or symptoms of HF.

I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.

C Structural heart disease with prior or current symptoms of HF.

I No limitation of physical activity. 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 without symptoms of HF, or symptoms of HF at rest.

D Refractory HF requiring specialized interventions.

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2 Flights of Stairs

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Early Atrial Filling (E wave)

Late Atrial Filling from atrial contraction (A wave)

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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)

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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)

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Echocardiography should not be used as a “tie breaker” to diagnose Heart Failure

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Apical 4 Chamber View

LVRV

RA LA

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1

2, 3

4

4. Pulmonary venous hypertension

2. Left atrial hypertension

3. Left atrial enlargement

1. Myopathicprocess in the left ventricle

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Risk Scoring

Validated multivariable risk scores can be useful to estimate subsequent risk of mortality in ambulatory or hospitalized patients with HF.

I IIa IIb III

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Risk Scores to Predict Outcomes in HFRisk Score Reference (from full-text guideline)/Link

Chronic HFAll patients with chronic HFSeattle 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 HFpEFI-PRESERVE Score (202)

Acutely Decompensated HF

ADHERE Classification and Regression Tree (CART) Model

(201)

American Heart Association Get With the Guidelines Score

(206) / http://www.heart.org/HEARTORG/HealthcareProfessional/GetWithTheGuidelinesHFStroke/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)

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Treatment of HFpEFRecommendations COR LOE

Systolic and diastolic blood pressure should be controlled according to published clinical practice guidelines I B

Diuretics should be used for relief of symptoms due to volume overload I C

Coronary revascularization for patients with CAD in whom angina or demonstrable myocardial ischemia is present despite GDMT

IIa C

Management of AF according to published clinical practice guidelines for HFpEF to improve symptomatic HF

IIa C

Use of beta-blocking agents, ACE inhibitors, and ARBs for hypertension in HFpEF IIa C

ARBs might be considered to decrease hospitalizations in HFpEF IIb B

Nutritional supplementation is not recommended in HFpEF

III: No Benefit C

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Pharmacological Treatment for Stage C HFpEF

Systolic and diastolic blood pressure should be controlled in patients with HFpEF 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 HFpEF.

I IIa IIb III

Coronary revascularization is reasonable in patients with CAD in whom symptoms (angina) or demonstrable myocardial ischemia is judged to be having an adverse effect on symptomatic HFpEF despite GDMT.

I IIa IIb III

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Pharmacological Treatment for Stage C HFpEF (cont.)

Management of AF according to published clinical practice guidelines in patients with HFpEF 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 HFpEF.

I IIa IIb III

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Pharmacological Treatment for Stage C HFpEF (cont.)

The use of ARBs might be considered to decrease hospitalizations for patients with HFpEF.

I IIa IIb III

Routine use of nutritional supplements is not recommended for patients with HFpEF.

I IIa IIb III

No Benefit

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Manage Comorbidities

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Questions/Comments?

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