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PULMONARY VENOUS PRESSURE
Input
Filling Emptying
ED volume x Stroke
= volume
EFeffective
LV Distensibility Contractility x
Relaxation Afterload
Left atrium Preload Heart
Mitral valve Structure rate
Pericardium
Diastolic function Systolic function
Output
CARDIAC OUTPUT
Block diagram of left ventricular pump performance
(Little, 2001)
Definition
Circulation 2002;105:1387-93.
J Am Coll Cardiol 2007;50:768-77.
Ann Med 2013;45:37-50.
Heart failure severity
NYHA Functional
Classification ACCF/AHA HF Staging
Clas Description Stag Description
s e
I No limitation of physical activity. A At high risk for HF but without structural
Ordinary physical activity does not heart disease or symptoms of HF
cause HF symptoms
II Slight limitation of physical activity. B Structural heart disease but without signs
Comfortable at rest, but ordinary or
physical activity results in symptoms of symptoms of HF
HF
III Marked limitation of physical activity. C Structural heart disease with prior or
Comfortable at rest, but less than current
ordinary activity causes symptoms of symptoms of HF
HF
IV Unable to carry on any physical activity D Refractory HF requiring specialized
without symptoms of HF, or symptoms
Circulation 2013;128:e240-327. interventions
of HF at rest
Risk factors for HF
HFpEF HFrEF
Age Coronary artery disease
Gender (females) Family history of heart disease
Hypertension Hypertension
Diabetes Diabetes
Obesity Obesity
www.biomerieux-diagnostics.com
HFpEF pathophysiology
Ventricular hypertrophy
Inflammation Neurohormones
LV
Input
Filling Emptying
ED volume x Stroke
= volume
EFeffective
LV Distensibility Contractility x
Relaxation Afterload
Left atrium Preload Heart
Mitral valve Structure rate
Pericardium
Diastolic function Systolic function
Output
CARDIAC OUTPUT
Block diagram of left ventricular pump performance
(Little, 2001)
Treatment for HFpEF
HFpEF Treatment options
Non-pharmacologic Pharmacologic
Diuretics
Sodium and fluid
ACE inhibitors/ARBs
restriction
Regular exercise Aldosterone
Weight loss antagonists
-blockers
Calcium channel
blockers
Digoxin
Statins
Diuretics in HFpEF
-blockers
Calcium channel blockers
Digoxin
-Blockers
Proposed benefits in HFpEF
Decrease chronotropy
Decrease myocardial oxygen demand
Increase left ventricular filling time
Efficacy data in HFpEF
Small trials have demonstrated improvement of HF
symptoms and left ventricular function with one
study demonstrating mortality benefit
Am J Cardiol 1997;80(2):207-9.
Eur J Heart Fail 2004;6:453-61.
J Am Coll Cardiol 2009;53:2150-8.
-Blockers in HFpEF
Mortality benefit?
Useful for patients with atrial fibrillation or a history
of coronary artery disease
Heart failure guidelines
First line medication for hypertension
management in HFpEF
Management of atrial fibrillation
Am J Cardiol 1990;66:981-86.
Int J Clin Pract 2002;56;57-62.
Calcium channel blockers in HFpEF
-blocker HFpEF
Non-DHP CCB
Digoxin Activation of Cardiac
sympathetic Renin
NS output
Vasoconstricti
Heart rate Angiotensin I
on
ACEI
Cardiac Angiotensin II ARB
filling time
Cardiac
remodeling
Cardiac Aldosterone
filling pressure Na/H2O
retention
Aldosterone antagonist
Diuretic
Adapted from Goodman & Gilman's The Pharmacological Basis of Therapeutics 2011.
Investigational therapies in HFpEF
Sildena
fil
Ranolazi
ne
Alegabriu
m
Pharmacotherapy 2011;31(3):312-31.
JAMA 2013;309(12):1268-77.
Mortality benefit
HFpEF HFrEF
Aldosterone antagonists
?
ACE inhibitors
ARBs
-blockers
Vasodilators
treatment recommendations
Circulation 2013;128:e240-327.
Eur Heart J 2012;33:1787-1847
Treatment of HFpEF
HFpEF Treatment Recommendations
Characteristic
Volume overload Diuretic
symptoms
Hypertension ACE inhibitor, ARB, -blocker