heart failure with preserved ejection fraction guidelines
heart failure with preserved ejection fraction guidelines
Reddy YNV, Carter RE, Obokata M, Redfield MM, Borlaug BA. However, reductions in cardiomyocyte calcium overload with ranolazine to date have not significantly improved myocardial relaxation and diastolic dysfunction[28]. Yusuf S, Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL, Olofsson B, Ostergren J CHARM Investigators and Committees. Fifty-one percent of patients with HFpEF have hypertension, whereas among patients with HFrEF, hypertension is present in 41%[67]. One population-based study found that after four years, 3.3% of patients with diastolic dysfunction on baseline echocardiography developed symptomatic heart failure, 23% had worsened diastolic dysfunction, and 9% had improved diastolic dysfunction.32 Over the subsequent six years of follow-up, 3% of patients with normalized diastolic dysfunction, 8% with mild diastolic dysfunction, and 12% of those with moderate to severe diastolic dysfunction developed clinical heart failure. Myocardial fibrosis also decreases myocardial capillary density, coronary perfusion reserve, and myocardial energy production[33]. Biomarkers of diastolic dysfunction and myocardial fibrosis: application to heart failure with a preserved ejection fraction. The specific conditions that can contribute to HFpEF are listed in Table Table11 which is adapted in part from[7,8]. Haykowsky MJ, Brubaker PH, John JM, Stewart KP, Morgan TM, Kitzman DW. This form of heart failure is becoming the dominant form of heart failure among older adults in the United States and in Europe due, in part, to the increasing longevity of the population. Hernandez AF, Hammill BG, O'Connor CM, Schulman KA, Curtis LH, Fonarow GC. Patients with HFpEF can have normal resting left atrial pressures but develop marked increases in left atrial pressures and pulmonary hypertension with exercise due to a decrease in LV diastolic compliance. Most commonly, these patients are elderly women with hypertension, ischemic heart disease, atrial fibrillation, obesity, diabetes mellitus, renal disease, or obstructive lung disease. Myocardial biopsies from patients with HFpEF, especially patients with hypertension and HFpEF, show an increase in the collagen volume fraction and an increase in myocardial fibrosis in comparison with patients without heart failure[29,30]. A caloric restriction diet is feasible and safe in older, obese patients with HFpEFs, and significantly improves patient dyspnea, peak oxygen consumption, and quality of life[64]. Before Recently a scoring system has been developed to facilitate the diagnosis of HFpEF in patients with dyspnea and distinguish these patients from patients with non-cardiac causes of dyspnea[52]. Rationale and design of the beta-blocker in heart failure with normal left ventricular ejection fraction (beta-PRESERVE) study. This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology. Author contributions: The author finished manuscript alone. Zakeri R, Chamberlain AM, Roger VL, Redfield MM. Patients with HFpEF and major obstructive coronary artery disease should be treated with coronary artery revascularization. In these patients, coronary revascularization is associated with a decrease in mortality and with outcomes that are not different from patients with HFpEF without CAD[62,63]. In this regard, a partial mechanical circulatory microdevice, which is inserted with a minimally invasive approach, directs blood from the left atrium into the subclavian artery[112]. Currently, 5.7 million people in the United States have heart failure and require 30.7 billion dollars per year for health care and medications. The ACC/AHA and ESC recommend combined endurance and resistance training for patients with HFpEF to improve exercise capacity, physical functioning, and diastolic function.3,5, Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers. Careers. The presence of CAD is associated with worse outcome in HFpEF, which appears to be independent of other predictors. van Heerebeek L, Hamdani N, Falco-Pires I, Leite-Moreira AF, Begieneman MP, Bronzwaer JG, van der Velden J, Stienen GJ, Laarman GJ, Somsen A, Verheugt FW, Niessen HW, Paulus WJ. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Ahmed A, Rich MW, Fleg JL, Zile MR, Young JB, Kitzman DW, Love TE, Aronow WS, Adams KF, Jr, Gheorghiade M. Effects of digoxin on morbidity and mortality in diastolic heart failure: the ancillary digitalis investigation group trial. Caloric restriction combined with endurance exercise, such as walking exercise for one hour three or more times per week, is additive and the combination can produce a 2.5 mL/kg/min increase in peak oxygen consumption and an increase in exercise capacity[64]. Left atrial decompression pump for severe heart failure with preserved ejection fraction: theoretical and clinical considerations. Microvascular Rarefaction and Heart Failure With Preserved Ejection Fraction. Mascherbauer J, Marzluf BA, Tufaro C, Pfaffenberger S, Graf A, Wexberg P, Panzenbck A, Jakowitsch J, Bangert C, Laimer D, Schreiber C, Karakus G, Hlsmann M, Pacher R, Lang IM, Maurer G, Bonderman D. Cardiac magnetic resonance postcontrast T1 time is associated with outcome in patients with heart failure and preserved ejection fraction. Transforming growth factor-: governing the transition from inflammation to fibrosis in heart failure with preserved left ventricular function. Feldman T. Paper presented at: The European Society of Cardiology;; 2018. Anticoagulation is recommended for patients with a CHA2DS2 VAS score 2. Physicians should obtain a brain natriuretic peptide or N-terminal probrain natriuretic peptide level for patients with possible heart failure if the diagnosis is uncertain. It recommends identifying and treating cardiovascular and noncardiovascular comorbidities, because most deaths and hospitalizations in patients with HFpEF are not due to chronic heart failure. Table Table66 lists the major pharmacologic studies that have been performed in patients with HFpEF and patients with heart failure with mid-range ejection fraction. The angiotensin receptor neprilysin inhibitor LCZ696 in heart failure with preserved ejection fraction: a phase 2 double-blind randomised controlled trial. The systemic arterial and ventricular stiffness in HFpEF is amplified by the coexistence of hypertension, chronic renal disease, and diabetes mellitus. Older age, hypertension, diabetes, and CAD increased the risk of heart failure. Tanaka S, Momose Y, Tsutsui M, Kishida T, Kuroda J, Shibata N, Yoshida T, Yamagishi R. Quantitative estimation of myocardial fibrosis based on receptor occupancy for beta2-adrenergic receptor agonists in rats. The potential role and rationale for treatment of heart failure with sodium-glucose co-transporter 2 inhibitors. Haykowsky MJ, Brubaker PH, Stewart KP, Morgan TM, Eggebeen J, Kitzman DW. If hypertension is present, it should be treated according to evidence-based guidelines. College of Public Health, University of South Florida, Tampa, FL33612, United States. Author disclosure: No relevant financial affiliations. Class IIa recommendation (Level of Evidence: B-NR) for measurement of other clinically available tests, such as biomarkers of myocardial injury or fibrosis, in patients with chronic HF for additive risk stratification. Atrial fibrillation should be treated using a rate-control strategy and appropriate anticoagulation. However, these patients have abnormal LV diastolic function with incomplete LV relaxation due to increased myocardial stiffness. For patients for whom the probability of HFpEF remains intermediate after history, physical examination, natriuretic peptide determinations, and echocardiography have been performed, invasive hemodynamic assessment of cardiac filling pressures, with provocative stress maneuvers such as exercise, is useful to make or exclude the diagnosis of HFpEF. Heart disease with preserved ejection fraction is a heterogenous syndrome with multiple different conditions that can contribute to the syndrome. Pulmonary artery systolic pressure > 35 mmHg indicative of pulmonary arterial hypertension. Echocardiography is a very useful noninvasive technique in the diagnosis of patients with HFpEF and often demonstrates the presence of LV hypertrophy or concentric LV remodeling with a LVEF that is 50% and a LV volume index that is < 97 mL/m2. A combination of decreased lung compliance and cardiac output leads to symptoms. In a small, single center study, catheter ablation of atrial fibrillation improved diastolic function in patients who maintained sinus rhythm[77]. Statin therapy may be associated with lower mortality in patients with diastolic heart failure: a preliminary report. Additionally, trials of angiotensin receptor blockers, digoxin, nitrates, and spironolactone raised concerns about adverse effects. The current hypotheses include: (1) Cardiomyocyte titin hypophosphorylation; (2) Vascular endothelial cell inflammation and dysfunction; (3) Abnormal calcium homeostasis; (4) Increased ventricular matrix formation; and (5) Obesity. In addition, since many hospitalizations and deaths in patients with HFpEF are due to noncardiovascular causes such as chronic obstructive lung, chronic kidney disease, and diabetes, these disorders must be identified early in the clinical course and aggressively treated. COPD: Chronic obstructive pulmonary disease; HFpEF: Heart failure with preserved ejection fraction. This is, in part, due to differences in trial design and patient population heterogeneity with differences in heart failure etiologies or stages of disease. Collagen expansion of the myocardial extracellular matrix, and especially an increase in the collagen type 1 fibers and the amount of crosslinked collagen, has an adverse effect on myocardial mechanical, electrical, and microvascular function and contributes to decreased diastolic function in HFpEF. Epidemiology of heart failure with preserved ejection fraction. Patients with suspected heart failure should be referred for two-dimensional transthoracic echocardiography to confirm the diagnosis and identify preserved or reduced ejection fraction. High circulating concentrations of the free oxygen radical peroxynitrite in patients with HFpEF increase cardiomyocyte protein phosphatase 2A activity, which decreases cardiomyocyte phospholambam phosphorylation, reduces sarcoplasmic reticulum Ca2+ uptake, and increases cardiomyocyte diastolic cytosolic Ca2+. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Heart Disease and Stroke Statistics-2018 Update: A Report From the American Heart Association. Consequently, patients with HFpEF should be subcategorized according to the presence or absence of CAD. In addition, increased intramuscular fat decreases the supply of oxygen to working muscles and can impair oxidative metabolism in the skeletal musculature and, in this manner, contributes to the decreased functional capacity experienced by patients with HFpEF[5,41]. Additional studies of SGLT2 inhibitors in patients with HFpEF and diabetes mellitus are in progress. Gu J, Fan YQ, Han ZH, Fan L, Bian L, Zhang HL, Xu ZJ, Yin ZF, Xie YS, Zhang JF, Wang CQ. Patients with ECV > 30% had decreased event-free survival during the subsequent four years. Class I recommendation (Level of Evidence: C-LD) for titration of GDMT to attain SBP <130 mm Hg in patients with HFpEF and persistent hypertension after management of volume overload. The annual mortality rate of these patients is 8%-12% per year. Despite similar rates of in-hospital complications in the two groups, patients with HFpEF are less likely to receive cardiology consultation while in the hospital than patients with HFrEF. Martnez-Martnez E, Jurado-Lpez R, Valero-Muoz M, Bartolom MV, Ballesteros S, Luaces M, Briones AM, Lpez-Andrs N, Miana M, Cachofeiro V. Leptin induces cardiac fibrosis through galectin-3, mTOR and oxidative stress: potential role in obesity. Atrial Fibrillation in Heart Failure With Preserved Ejection Fraction: Association With Exercise Capacity, Left Ventricular Filling Pressures, Natriuretic Peptides, and Left Atrial Volume. After 17.6 mo of follow-up, the hospitalization rate was 50% lower in patients where medical treatment decisions were made based on the pulmonary artery pressure measurements[111]. Two large trials examining candesartan (Atacand) and irbesartan (Avapro) failed to show reductions in mortality or all-cause hospitalization.16,17 A Cochrane meta-analysis found no difference in total hospitalizations or mortality in patients treated with an angiotensin receptor blocker, and noted an increased rate of adverse events (number need to harm = 33).18 A trial comparing perindopril (Aceon) with placebo showed no difference in all-cause mortality, heart failure hospitalization, or all-cause hospitalization at 2.1 years.19, Beta Blockers. Patients with HFpEF and coronary artery disease who have indications should be offered revascularization. The MICE rule states that in patients with suspected heart failure, echocardiography is recommended for those with a history of myocardial infarction and basilar lung crackles, or in any male with ankle edema. Measurement of natriuretic peptides is useful in the evaluation of patients with suspected heart failure with preserved ejection fraction in the ambulatory setting. However, the ECV fraction can be normal in as many as one-third of patients with HFpEF, which demonstrates the pathophysiological variation in this syndrome and the necessity to utilize the patients history, the physical examination, laboratory data, echocardiography, and, if necessary, cardiac catheterization in order to establish the diagnosis. Mamas MA, Caldwell JC, Chacko S, Garratt CJ, Fath-Ordoubadi F, Neyses L. A meta-analysis of the prognostic significance of atrial fibrillation in chronic heart failure. moc.liamg@dmgninnehtrebor. The following are summary points to remember about the 2017 American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure (HF): Stage C HF With Reduced Ejection Fraction (HFrEF): Summarized earlier here in a previous Journal Scan on the HF Focused Update on Pharmacological Therapy. Medical treatment based on pulmonary artery pressure monitoring with a permanently implanted right pulmonary artery microsensor significantly reduces hospitalizations for treatment of heart failure. Experience with atrial catheter ablation of atrial fibrillation in patients with HFpEF is limited. Zile MR, Brutsaert DL. P-Reviewer: Nurzynska D, Ueda H S-Editor: Dou Y L-Editor: A E-Editor: Zhang YL, National Library of Medicine Understanding heart failure with preserved ejection fraction: where are we today? More than 80% of patients with heart failure with HFPEF, are overweight or obese and deconditioned. In this regard, diuretic drugs are effective for blood pressure control and for the prevention of volume overload. Left atrial enlargement is oftentimes present with a left atrial volume index > 34 mL/m2 in patients who are not in atrial fibrillation. Results of the Swedish Doppler-echocardiographic study (SWEDIC), Yamamoto K, Origasa H, Hori M J-DHF Investigators. Patients with HFpEF and chronotropic incompetence are currently being tested with rate-adaptive atrial pacing (government trial {"type":"clinical-trial","attrs":{"text":"NCT02145351","term_id":"NCT02145351"}}NCT02145351). Sherazi S, Zarba W. Diastolic heart failure: predictors of mortality.
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