Diastolic Heart Failure Diagnosis and Treatment Paul J. Kovack, DO, FACOI, FACC

Disclosure I have no conflict of interest for this presentation

Outline Background Definition and Diagnostic Criteria Etiology Pathophysiology Clinical Diagnosis Management

Backround CHF affects 5 million Americans 400,000 new cases & 800,000 hospitalizations annually CHF : primarily a disorder of the elderly Among the elderly, it is the most frequent hospital discharge Over 10 billion health care dollars

Backround Among the elderly, cardiovascular disease is the MOST common cause of mortality and morbidity. In 1900, 4% of population was over 65. Now 30% 10,000 people turn 65 every day In the US currently, 5 million people have CHF. ½ these cases are from CHF with preserved LV function.

Mortality SHF vs DHF

DHF more likely to die from non-CV cause

Definition Diastolic dysfunction is not the same as Diastolic CHF Diastolic dysfunction characterizes abnormal relaxation of the LV. It is essentially an echo finding. Diastolic CHF describes a clinical syndrome of CHF in patient with preserved LV function. Diastolic heart failure (DHF) or HFpEF

Diagnostic Criteria For diastolic dysfunction, this relies on echo criteria Multiple factors enter into the equation Most are related to aging and hypertension

Normal diastolic function Occupies about 2/3 of the cardiac cycle. Takes longer than systole Active process, requires energy Abnormalities of diastolic function ALWAYS precede those of systolic function. So patients with systolic dysfunction always have diastolic dysfunction

CHF is a Clinical Diagnosis Patient has dyspnea with risk factors such as hypertension, diabetes, ischemia, elderly Subjective signs such as orthopnea and PND Clinical exam shows signs of HF , S4. CXR confirms pulmonary congestion with a normal sized cardiac silhouette ECG may show LVH, Atrial fibrillation. BNP elevated

BNP is lower in DHF 1/3 that of SHF Can be normal

BNP is lower in DHF

Systolic vs Diastolic Congestive heart failure Exertional Dyspnea Paroxysmal Nocturnal Dyspnea Orthopnea Jugular Venous Distinction Lung Crackles Displaced Aprical Impulse S4 S3 Systolic Heart Failure Diastolic Heart Failure Adapted from Echeverria et al, 1983

Is it systolic heat failure or is it diastolic heart failure? Physical exam CXR BNP Need to look at echo

Normal Diastolic filling 1. Isovolumic Relaxation 2. Early rapid diastolic filling phase 3. Diastasis 4. Late diastolic filling due to atrial contraction Quinones, ASE Review 2007

Normal Diastolic function When LV pressure becomes less than LA pressure, MV opens Rapid early diastolic filling begins. Driving force is predominantly elastic recoil and normal relaxation. ~80% LV filling during this phase

Normal Diastolic function As a result of rapid filling, LV pressure rapidly equilibrates with and may exceed LA pressure. Results in deceleration of MV inflow. Late diastolic filling is from atrial contraction. It’s ~ 20% LV filling.

MV inflow Patterns 5 stages – Normal and Stages I – IV diastolic dysfunction Stage I – Impaired relaxation Stage II – Pseudo-normal Stage III – Restrictive Filling, reversible Stage IV – Restrictive Filling, irreversible

MV PW inflow patterns

Stage I

Stage I

Stage II, Pseudonormal

Stage II

Stage II Valsalva ➔➔➔

Stage III

Stage III

Diastolic Dysfunction Grade 1 Grade 2 Grade 3 Grade 4 LV pressure E Mitral flow Tissue Doppler e’ Pulmonary vein Using these Doppler variables, we can grade diastolic dysfunction as we grade heart failure symptoms using NYHA classification. This grading system was proposed by Dr. Tajik of our institution and corrleates well with degree of diastolic dysfunction, filling pressure, and naturally patient’s prognosis. Grade 1 diastolic dysfunction represents mild dysfunction with impaired myocardial relaxation, but filling pressure is normal. In this situation, as long as diastolic filling period is well preserved, patient does not experience significant symptoms. Grade 2 diastolic dysfunction is same as pseudonormalized filling pattern with mild to moderate elevation of filling pressure. Grade 3 and 4 diastolic dysfunction represents most advanced stage, called restrictive pattern, with marked elevation of filling pressure and decreased LV operating compliance. The difference between grade 3 and 4 is reversibility of restrictive diastolic filling. It is important to remember that myocardial relaxation is impaired in all stages of diastolic dysfunction so that (Click) mitral annulus E’ velocity is decreased and mitral flow propagation velocity is reduced. E/e’ < 10 10 -15 >15 >15 CP1008785-63

As LV filling pressure ↑ 45 40 35 30 25 20 15 10 5 E/e’ PCWP (mm Hg) r = 0.87 n = 60 As LV filling pressure ↑ Mitral E Annulus e Therefore, as LV filling pressure increases, mitral inflow E velocity increases, but mitral annulus E’ velocity decreases. As a result, E/E’ ratio increases. According to the investigations from Baylor and our institution by Dr. Steve Ommen, E/E’ ratio of 15 or greater usually indicates PCWP 20 mmHg or higher. E/e Nagueh et al: JACC, 1997 Ommen et al: Circ, 2000

E/E’ is a robust clinical marker What the ratio means? > 15  elevated filling pressures < 8  Nl 8 – 15  ??? Nagueh et al, JACC 1997; 30: 1527 - 1533

Etiology

Causes of Diastolic dysfunction  Heart Failure Hypertension Obesity Sleep apnea Atrial fibrillation

Other Causes Cardiomyopathy CAD Valvular heart disease Diabetes Hypertrophic Restrictive, Infiltrative, eg Amyloid CAD Valvular heart disease Diabetes Obesity Sleep Apnea Constrictive pericarditis

Pathophysiology An inability to increase stroke volume by Frank-Starling mechanism despite severely increased LV filling pressure is indicative of diastolic dysfunction Impairment of ventricular relaxation and decreased compliance of the left ventricle. With mild dysfunction, the ventricle can compensate with an increase in the late filling phase until the end- diastolic volume returns to normal. In severe cases, the ventricle is so stiff that the left atrium fails, and the end-diastolic volume cannot be normalized. This leads to reduced stroke volume and cardiac output.

DHF is an important cause of pulmonary hypertension

Group 2 Pulmonary hypertension includes SFH, valvular heart disease and DHF

Management Primary prevention Smoking cessation Aggressive control of hypertension, hyperlipidemia and CAD including revascularization Weight loss Limiting alcohol intake Diastolic dysfunction can be present for many years before it is clinically evident Early diagnosis and treatment prevents irreversible structural abnormalities and systolic dysfunction

Alcohol and atrial fibrillation J Am Coll Cardiol 2016;68:2567-76

TOPCAT trial

DIG Trial – HFpEF cohort No effect on mortality Fewer HF hospitalizations with dig More ACS hospitalizations with dig

Beta blockers in DHF: Very little data

Taylor, International Journal of Cardiology 2012 Effects of exercise training for heart failure with preserved EF

Heart failure is covered for rehab Only if it is due to systolic dysfunction

Interatrial shunt device for HFpEF Outcomes at 1 year Device implanted in 64 patients to allow small amount of left to right shunting to reduce elevated left atrial pressure Improvemant in 6 minute walk test Improvement in NYHA class Improvement in HF quality of life scores REDUCE LAP-HF Circulation 2016 Nov 16; doi 10.1161

Guideline driven treatment of DHF ACC/AHA guidelines 2005 similar to 2001 2009 similar to 2005 2013 similar to 2009 2016 is pharmacologic update to now include ARNI. No new information regarding DHF

Class I indications

ACC/AHA Guidelines 2009 (and 2013) Class IIa Coronary revascularization if ischemia is thought to be causing diastolic dysfunction

ACE/ARB/BB/CaB in DHF Use if you have another indication Hypertension Diabetes CAD A fib If you have to choose between diuretic and ACE/ARB/BB/CaB Choose diuretic is there is congestion

Conclusions There has been a steady rise in prevalence of CHF with preserved LV function. By the 7th decade, incidence of diastolic CHF = systolic CHF By the 8th decade, incidence of diastolic CHF > systolic CHF The survival of patients with the clinical syndrome of heart failure is similar in those with preserved versus those with a reduced LV ejection fraction

Conclusions Recognize (amyloid, constriction, restriction) An important component of Group 2 PHT Treatment: Remove iatrogenic agents (eg NSAIDS) Diuretics BP control HR control Ischemia. Dyspnea as angina equivalent Rhythm control in A fib if still symptomatic with rate control