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TRANSCRIPT
HFrEF vs HFpEF
reduced EF vs preserved EF
Heart Failure ECHO Clinic
Virtual Heart Failure Consultation and Education
Prof Ken McDonald & Dr. Patricia Campbell
xth January 2017
• ‘HF is a clinical syndrome characterised by • typical symptoms +/- signs
• caused by a structural or functional cardiac abnormality
• that results in ↓ cardiac output and/or ↑ intracardiac pressures’
• HF with reduced ejection fraction (HFrEF)
• EF < 40%
• HF with preserved ejection fraction (HFpEF)
• EF > 40%
Definition
• HF-MREF new category and falls into the HF-PEF classification
• Unknown entity, ignore for now
Latest Guidelines
ESC HF Guidelines 2016. Eur J Heart Fail. 2016 Aug;18(8):891-975
• HFrEF
• Younger
• Ischaemia
• Inherited and acquired cardiomyopathies
• HFpEF
• Older
• Female
• Multiple co-morbidities (HTN, T2DM, renal impairment)
Population
HFrEF
Triple therapy with ACEi/ARB, B blocker and MRA
ARNI (Sacubitril/Valsartan)
Ivabradine/nitrates/digoxin
ICD +/- CRT
HFpEF
Evidence doesn’t support use of triple therapy
Diuretics remain cornerstone of therapy
Optimising treatment of co-morbidities
Ongoing studies to assess ARNI in HF-PEF population
Differences in treatment
HF activates 3 neurohormonal systems
Levin et al. N Engl J Med 1998;339:321–8 Nathisuwan & Talbert. Pharmacotherapy 2002;22:27–42 Kemp & Conte. Cardiovascular Pathology 2012;365–71 Schrier & Abraham. N Engl J Med 2009;341:577–85
Sympathetic
nervous system
Renin-angiotensin-
aldosterone system
Vasoconstriction Blood pressure
Sympathetic tone Aldosterone Hypertrophy
Fibrosis
Ang II AT1R
HF SYMPTOMS &
PROGRESSION
Natriuretic peptide
system
Vasodilation Blood pressure Sympathetic tone Natriuresis/diuresis Vasopressin Aldosterone Fibrosis Hypertrophy
NPRs NPs
Epinephrine
Norepinephrine α1, β1, β2
receptors
Vasoconstriction RAAS activity
Vasopressin Heart rate
Contractility
HFrEF – Triple Therapy Standard
ESC HF Guidelines 2016. Eur J Heart Fail. 2016 Aug;18(8):891-975
LCZ696: enhancement of natriuretic and other vasoactive peptides, with simultaneous RAAS suppression
Evolution of therapy in HF: Sacubitril/Valsartan as a new alternative to an ACEI or ARBs in patients with HFrEF1
1. McMurray et al. Eur J Heart Fail 2013;15:1062–73
Figure references:
Levin et al. N Engl J Med 1998;339:321–8
Nathisuwan & Talbert. Pharmacotherapy 2002;22:27–42 Kemp & Conte. Cardiovascular Pathology 2012;365–71 Schrier & Abraham. N Engl J Med 2009;341:577–85
Vasoconstriction Blood pressure
Sympathetic tone Aldosterone Hypertrophy
Fibrosis
Ang II AT1R
HF SYMPTOMS &
PROGRESSION
INACTIVE FRAGMENTS
Vasodilation Blood pressure Sympathetic tone Natriuresis/diuresis Vasopressin Aldosterone Fibrosis Hypertrophy
NPRs NPs
Epinephrine
Norepinephrine α1, β1, β2
receptors
Vasoconstriction RAAS activity
Vasopressin Heart rate
Contractility
SNS β-blockers
RAAS RAAS inhibitors
(ACEI, ARB, MRA)
NP system
Neprilysin inhibitors
LCZ696
Further RAAS adjustments if ongoing issues
ESC HF Guidelines 2016. Eur J Heart Fail. 2016 Aug;18(8):891-975
HF-PEF recommendations
ESC HF Guidelines 2016. Eur J Heart Fail. 2016 Aug;18(8):891-975
Different populations
Different therapies
Different reasons for
hospitalisation
Similar mortality
outcomes and
hospitalisation rates
Outcomes: HF-REF vs HF-PEF
Rajdip Dulai et al. Br J Cardiol 2016;23
P = 0.551
To apply for the CME Certification:
Return signed CME form to:
Ms Rosemary Geoghegan
Fax: 01-2713070
E-mail: [email protected]
Thank you for your participation