R2 talk – Understanding HFpEF
Dr. Abdelhamid
1. Definition
a. Heart failure in general is when the heart’s oxygen delivery is not meeting the body’s oxygen demand and if it does meet it, it is with high chamber filling pressures
b. Heart failure with preserved ejection fraction is a specific type of heart failure that implies:
i. Diastolic dysfunction (LV stiffness or prolonged relaxation)
ii. EF ≥ 50%
c. There must always be symptoms of congestion (edema, pulmonary edema, hepatic congestion, Cardiorenal syndrome) to truly be in heart failure
2. Epidemiology, prevalence, mortality
a. HFpEF makes up 50% of all new heart failure cases
b. Most elderly with new heart failure will have HFpEF
c. HFpEF is more common in:
i. Women
ii. Elderly
d. HFpEF has less mortality from CV causes than HFrEF but elevated all-cause mortality when compared to HFrEF. However, other parameters such as quality of life, rate of hospitalizations and duration of hospitalizations are the same between the 2 entities.
e. HFpEF has an increased all-cause mortality than those without heart failure
3. Pathophysiology
a. The major risk factors [listed below] create a proinflammatory environment for the heart, leading to fibrosis, ischemia, myocyte hypertrophy and altered cell signaling
i. HTN (#1 associated risk factor with HFpEF)
ii. DM
iii. Obesity
iv. Metabolic syndrome
v. CKD
vi. Anemia
vii. CAD – more often associated with HFrEF
b. The systemic inflammation leads to LV stiffening and prolonged relaxation increased LV end diastolic pressures LA responds by increasing its own pressures and dilating eventually this compensatory mechanism fails pulmonary congestion Pulmonary vasculature remodels and leads to pulmonary HTN & pulmonary edema.
i. Concentric hypertrophy (LV wall thickens) is most often associated with HFpEF but eccentric and normal geometry can be seen.
ii. LV remodeling is heterogenous in HFpEF and there are many phenotypes
c. A. fib is often associated with HFpEF because of the LA dilation observed
i. Loss of Atrial kick
ii. Decreased filling time (aka decreased diastole) due to tachycardia
iii. Early rhythm control may lead to less CV death, stroke and hospitalization for HF exacerbation; but this has yet to change our current understanding that rate and rhythm are equally beneficial
1. This new study incorporated A. fib ablation with early A. fib
d. Etiologies of HFpEF:
i. HTN
ii. Valvular disease
iii. Amyloidosis, other restrictive diseases
iv. Ischemic disease; again most often seen with HFrEF
4. Clinical manifestations
i. Elevated LV-EDP leads to dyspnea on exertion, decreased Oxygen consumption, increased respiratory rate
b. Heart failure symptoms are centered around congestion
i. Pulmonary edema
ii. BLE edema
iii. Hepatic congestion
iv. Cardiorenal syndrome
5. Diagnostic evaluation
a. Echo
i. Easily measures and stratifies patient care
ii. Measure EF and monitor systolic and diastolic function
b. BNP: related to end-diastolic wall stress
i. Decreased in obesity
ii. Increased in A. fib
iii. HfpEF will often have lower BNP levels because of the increased LV wall thickness that decreases wall tension
c. Imaging will show congestion (CXR, RUQ US, etc.)
d. H2FPEF: Scoring system that shows likelihood of HFpEF
i. Based on obesity, HTN, A. fib, PAH, age, filing pressures
ii. 0-1 score – low probability
iii. 2-4: intermediate probability, follow-up with hemodynamic exercise testing
iv. 5-6: high probability
e. Remember, heart failure is a clinical diagnosis and does not depend on specific lab or imaging findings. These are all just supportive of the clinical picture
6. Management
a. There has been no regimen proven to benefit mortality or decrease hospitalizations in HFpEF patients
i. In HFrEF, we think of our goal directed medical therapy, which includes ACEi/ARB, BB, nitrates, hydralazine, Spironolactone. These have never been shown to be effective in HFpEF.
ii. Somewhat exceptions:
1. ARB & spironolactone have shown to reduce rate of hospitalizations in the CHARM-Preserved and TOP-CAT study, respectively. These are both class IIb recommendations to start in HFpEF.
a. Side effects of electrolyte and renal disturbance have limited their use
iii. Continue to use ACEi/ARB, BB or other medications if they are indicated for other treatments, such as HTN, A. fib, ischemic heart disease
b. HFpEF management centers on symptom control and modifying risk factors
i. Diuretics for symptom control
1. New studies (CHAMPION) showing benefit with wireless pulmonary artery catheter to guide diuretic treatment
ii. HTN
1. Stricter blood pressure has shown beneficial for HFpEF patients, but must balance it out with side effects of hypotension and syncope.
a. ACCORD did not show benefit with strict BP control in diabetic patients
iii. Statins
1. Observed and retrospective trials have seen improvement in mortality
2. No randomized control study to prove this yet
iv. Exercise and weight loss
v. SGLT2 inhibitors in diabetic patients
1. SGL2 inhibitors are indicated in all HFrEF patients, regardless of diabetic status
c. New phenotyping analysis has shown that there are 3 distinct groups of HFpEF with different patient characteristics, cardiac and electric remodeling and risk outcomes.
i. Can we create different treatments for these 3 different groups?
References:
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Pagel PS, Tawil JN, Boettcher BT, Izquierdo DA, Lazicki TJ, Crystal GJ, et al. Heart Failure With Preserved Ejection Fraction: A Comprehensive Review and Update of Diagnosis, Pathophysiology, Treatment, and Perioperative Implications. J Cardiothorac Vasc Anesth. 2021;35(6):1839-59.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Jr., Colvin MM, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Card Fail. 2017;23(8):628-51.
Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults greater than or equal to 75 years: A randomized clinical trial. JAMA 2016;315:2673–82.
Abraham WT, Adamson PB, Bourge RC, et al. Wireless pulmonary artery haemodynamic monitoring in chronic heart failure: A randomised con- trolled trial. Lancet 2011;377:658–66.
Fukuta H, Goto T, Wakami K, et al. The effect of statins on mortality in heart failure with preserved ejection fraction: A meta-analysis of propen- sity score analyses. Int J Cardiol 2016;214:301–6.
Zinman B, Wanner C, Lachin JM, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med 2015;373: 2117–28.
Sanjiv J. Shah. Circulation. Phenomapping for Novel Classification of Heart Failure With Preserved Ejection Fraction, Volume: 131, Issue: 3, Pages: 269-279, DOI: (10.1161/CIRCULATIONAHA.114.010637)
Kirchhof P, Camm AJ, Goette A, Brandes A, Eckardt L, Elvan A, et al. Early Rhythm-Control Therapy in Patients with Atrial Fibrillation. N Engl J Med. 2020;383(14):1305-16.
