Diastolic Dysfunction - Annals of Internal Medicine
Download
Report
Transcript Diastolic Dysfunction - Annals of Internal Medicine
* For Best Viewing:
Open in Slide Show Mode
Click on
icon
or
From the View menu, select the
Slide Show option
* To help you as you prepare a talk, we have included the
relevant text from ITC in the notes pages of each slide
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
in the clinic
Heart Failure With
Preserved Ejection
Fraction
(Diastolic Dysfunction)
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Terms of Use
The In the Clinic® slide sets are owned and copyrighted by the
American College of Physicians (ACP). All text, graphics,
trademarks, and other intellectual property incorporated into the
slide sets remain the sole and exclusive property of ACP. The slide
sets may be used only by the person who downloads or purchases
them and only for the purpose of presenting them during not-forprofit educational activities. Users may incorporate the entire slide
set or selected individual slides into their own teaching
presentations but may not alter the content of the slides in any way
or remove the ACP copyright notice. Users may make print copies
for use as hand-outs for the audience the user is personally
addressing but may not otherwise reproduce or distribute the slides
by any means or media, including but not limited to sending them as
e-mail attachments, posting them on Internet or Intranet sites,
publishing them in meeting proceedings, or making them available
for sale or distribution in any unauthorized form, without the
express written permission of the ACP. Unauthorized use of the In
the Clinic slide sets constitutes copyright infringement.
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What is the difference between HFpEF,
diastolic dysfunction, and diastolic HF?
Heart failure with preserved ejection fraction (HFpEF)
Preferred term (ACC/AHA)
Most often have abnormalities in diastolic function
(non-diastolic abnormalities in CV function also)
Diastolic heart failure / Diastolic dysfunction
Other common terms for HFpEF but less specific
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What’s the difference between HFpEF & HFrEF?
Left ventricle doesn’t dilate in HFpEF
Some treatments for HFrEF aren’t effective in HFpEF
HFpEF:
Older and more often female
Higher frequency of hypertension; lower CAD
Prevalence HFpEF rising 1% / yr relative to HFrEF
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
HFpEF is not “benign”
Similar functional decline, hospital readmission rates,
economic costs as HFrEF
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What are the risk factors for HFpEF?
For HF in general
Age
Hypertension
Obesity
Dyslipidemia
Insulin resistance
For HFpEF
Older, more hypertensive, and higher prevalence of AF
(than in HFrEF)
CAD prevalence comparatively lower
More common in women (by 2:1)
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Are any interventions effective for primary
prevention of HFpEF?
Control hypertension
Main factor in development and progression
Lower systolic & diastolic according to guidelines
Treat hyperlipidemia and hyperglycemia
Reduces risk for HFpEF and HFrEF
Encourage smoking cessation, exercise, healthy diet
Moderate alcohol consumption among patients who drink
Weight reduction can prevent diabetes, AF, obstructive
sleep apnea, hypertension
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
CLINICAL BOTTOM LINE: Prevention…
Reduce risk for HF
Reduce systolic & diastolic BP <140/90 mm Hg (<130/80 mm Hg
if htn + diabetes or renal disease)
Use diuretic-based antihypertensive therapy, ACE inhibitors,
and beta-blockers
Glycemic control helps to prevent HF in diabetes mellitus
Treat hyperlipidemia in patients with Hx of MI
Encourage weight loss, smoking cessation; regular exercise;
healthy diet
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Which presenting features help to
distinguish HFpEF from HFrEF?
HFpEF
Hx hypertension & AF slightly more prevalent
Rapid onset of dyspnea with marked hypertension,
particularly in elderly women
AF or LV hypertrophy on ECG
HFrEF
Cardiac output somewhat lower, CAD more prevalent
Slower-onset HF with Hx coronary disease, particularly in
middle-aged men
LBBB or evidence prior ischemic injury
Both often present with…
Dyspnea, impaired exercise tolerance, orthopnea,
paroxysmal nocturnal dyspnea
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Which diagnostic tests should the clinician
order for patients with suspected HF?
Electrocardiography
Radiography
Echocardiography
Laboratory tests
Plasma BNP or NT-proBNP
CBC: ? anemia, serum electrolytes, creatinine, glucose,
liver function, urinalysis
Renal function and electrolytes
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What additional tests should clinicians
consider for patients with suspected HFpEF?
Cardiac catheterization (for new-onset HF)
Left heart: measure LVEDP + coronary arteriography
Right heart: if needed to evaluate valvular heart disease
suggested by echo, or if pulmonary hypertension not
explained by left heart disease
When abnormal myocardial function present
(? Infiltrative processes, constriction, others), consider:
Myocardial or fat pad tissue CT or MRI
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What are the criteria for establishing the
diagnosis?
History and physical examination
Radiography
BNP levels
Echocardiography
Requirements for Diagnosis
• Presence of signs and/or symptoms of HF
• Preserved systolic LV function (EF ≥45%–50%)
• Evidence of diastolic LV dysfunction, elevated LV filling
pressures, or surrogate markers of diastolic LV dysfunction
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What is the role of BNP in diagnosis and
management?
Levels usually lower in HFpEF than HFrEF
When elevated: strong independent predictors of
clinical events in HFpEF
No consensus on use to guide medical therapy
NT-proBNP
Superior for evaluating suspected acute HFpEF
Sensitive & specific for Dx acute HF in emergency dept:
>450 pg/mL (<50y); >900 pg/mL (≥50y)
BNP
Falsely negative in up to 20% with HFpEF
Doesn’t correlate with symptoms
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
CLINICAL BOTTOM LINE: Diagnosis…
Signs and symptoms
Impaired exercise tolerance, orthopnea, dyspnea, and signs
suggestive of HF
History may include hypertension and atrial fibrillation
Diagnosed based on H&P exam, x-rays, BNP levels, & ECHO
Criteria for diagnosing HFpEF
Signs / sxs of HF
Preserved systolic LV function (EF ≥45%–50%)
Evidence of: diastolic LV dysfunction, elevated LV filling
pressures or surrogate markers of diastolic LV dysfunction
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
How should HFpEF be treated?
Reduce preload
Use diuretics and vasodilators
BUT NOTE: Assess Volume Status carefully as aggressive
reduction may cause hypotension if hypertensive &
normovolemic
Consider control of hypertension with vasodilators alone
Treat acute HFpEF
First-line therapy: Vasodilators
I.V. nitrates + furosemide (improve cardiac output and
reduce the symptoms)
Nitroglycerin to relieve acute pulmonary edema
Avoid aggressive diuresis (may cause hypotension)
Heart rate control, with particular attention in rapid AF
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Provide long-term treatment of hypertension
Improves diastolic tissue velocity in hypertension w/o HF
If no comorbid conditions: thiazide diuretics
If coronary atherosclerosis or AF: beta-blocker
Reduce / reverse adverse remodeling: ARBs
Manage Atrial Fibrillation
In HFpEF + AF: restore normal HR and NSR to improve
symptoms (maybe not outcomes)
Rate control first: AV nodal blocking agents + β-blockers
Rhythm control: when rate control not achieved or when
symptoms persist despite rate control
Immediate electrical cardioversion: new-onset AF and
myocardial ischemia, symptomatic hypotension, or
pulmonary congestion or rapid ventricular response
uncontrolled by appropriate pharmacologic measures
Anticoagulation: to reduce thromboembolism risk
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
When should inotropic agents be
considered?
Not indicated
Increase inotropy and heart rate
Have no lusitropic effects
Studies on digoxin showed no significantly positive result
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
How does drug therapy for HFpEF differ
from that of HFrEF?
Many of the same drugs are used… but evidence differs
HFrEF: Improved mortality and morbidity with ACE
inhibitors, ARBs, β-blockers, and aldosterone antagonists
HFpEF: No similar improvements found from the therapies
HFpEF focus: symptom relief, BP and heart rate control
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Are any novel drug therapies being
investigated for HFpEF?
Spirinolactone
Proven therapy for HFrEF
Under investigation for HFpEF (TOPCAT study)
Sildenafil (phosophodiesterase-5 inhibition)
In small study: Reduced pulmonary arterial pressure,
improved right ventricular systolic function, reduced right
atrial pressure, improved QOL
Efficacy being studied in larger RELAX trial
Requires further / completion of studies
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What are potential triggers of
decompensation?
Dietary indiscretion
Use of NSAIDs
Medication nonadherence
Dysrhythmias (particularly AF)
Ischemia or infarction
Hypertension
Worsening renal function
Valvular cardiac disease
Alcohol abuse
Infection
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What is the role of diet and monitoring weight?
Advise patients to weigh themselves daily
Unexpected weight gain may warrant prompt action
If weight gain, increased edema, other HF symptoms
occur, patient should promptly call health care provider
Sodium restriction recommended in symptomatic HF
To prevent fluid retention
Fluid restriction (≤1.5-2 L/day)
For severe symptoms of HF, especially hyponatremia
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What should clinicians advise patients with
HFpEF about exercise?
Advise regular, moderate daily activity
Aerobic exercise especially beneficial
Improve CV performance
Lowers blood pressure
Prevents or reverses deconditioning
Increases energy levels
Reduces symptoms of HF
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
How should clinicians assess the response
to therapy for HFpEF?
? Symptom alleviation
? Functional capacity improvement
? Hospitalizations for decompensated HFpEF decreased
Other treatment targets…
Optimal blood pressure control
Adequate heart rate control in AF
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What is the prognosis of HFpEF?
Annual death rate ≈5%
≈50% die of noncardiovascular diseases
Risk factors for mortality in HFpEF
Increasing age, male gender
Higher natriuretic peptide levels, higher NYHA class
Coronary artery or peripheral vascular disease
Diabetes mellitus, chronic renal insufficiency
Lower EF, restrictive filling pattern on Doppler ECHO
Low and very high BMI (in HFpEF)
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
How should patients with HFpEF be followed?
Educate patients on signs of fluid retention
Provide guidelines for using a flexible diuretic regimen
Provide telephone access to health care providers
Emphasize low-salt diet + medical regimen compliance
Frequency of follow-up visits depends stability of patient
See w/in 7d of hospital discharge for decompensated HF
See well-compensated patient every 4 to 6 months
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
When should patients with HFpEF be
hospitalized?
Respiratory failure secondary to pulmonary edema
Moderate to severe volume overload
Atrial fibrillation with rapid ventricular response
Severe hypotension or hypertension
Need for close monitoring during therapy (e.g., of renal
function, electrolytes)
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
When should clinicians consider
consulting a cardiologist?
Diagnosis of HFpEF uncertain
Cause of HFpEF unclear
Patient symptomatic despite treatment
Frequent hospitalizations for decompensation
Comorbid cardiac conditions complicate management
(CAD or dysrhythmia)
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
CLINICAL BOTTOM LINE: Treatment…
Treating the triggers of HF decompensation
Relieve acute pulmonary congestion and intravascular and
interstitial volume excess
Alleviate symptoms, improve functional capacity, and
decrease hospitalizations
Aim for optimal BP & adequate heart rate control in AF
Educate patients to recognize the signs of fluid retention
Use flexible diuretic regimen if needed
Emphasize low-salt diet + medical regimen compliance
Consult cardiologist when…
Diagnosis uncertain or cause unclear
Patient symptomatic despite treatment
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.