Heart failure with borderline left ventricular systolic dysfunction: what's new in prognosis and management?. Adj Ass Prof Ong Hean Yee MBBCh BAO, ASCeXAM, FRCP, FESC Senior Consultan
Trang 1Heart failure with borderline
left ventricular systolic dysfunction:
what's new in prognosis and management?
Adj Ass Prof Ong Hean Yee
MBBCh BAO, ASCeXAM, FRCP, FESC
Senior Consultant and Head of Department
Department of Cardiology
Khoo Teck Puat Hospital
Trang 2Astra Zeneca, Bayer
All Honorariums donated to Department Research and Training Fund
Trang 3Ejection Fraction not mentioned
Diagnosis was based on
1 Low
• Cardiac Index
2 High
• PCWP (surrogate for LA / LVEDP)
• Systemic Vascular Resistance
Trang 4Ejection Fraction not mentioned
Diagnosis was based on
1 Clinical
1 Symptoms
2 Oedema
2 CXR
Trang 5Ejection Fraction < 45% used
Trang 6NELSON, N COHN, GORLIN CIRC 1975, 52: 408
Ejection Fraction < 30 % vs < 50%
Trang 7Heart Failure Preserved EF (HFPEF)
Ziles N Engl J Med 2004;350:1953-9
Trang 8Heart Failure Preserved EF (HFPEF)
Ziles N Engl J Med 2004;350:1953-9
LVEDP
~ 5mmHg
Trang 9Heart Failure Preserved EF (HFPEF)
Ziles N Engl J Med 2004;350:1953-9
LVEDP
~ 5mmHg LVEDP
~ 17mmHg
Trang 10Preserved EF Reduced EF
Preserved versus Reduced
Trang 11Diagnosis: Prognosis
Vasan et al Framingham Study JACC 1999, 331, 1948
Trang 12Diagnosis: Prognosis
MacDonald et al Am J Cardiol 2016 Jul 29 (published ahead of print)
Trang 13Diagnosis: Prognosis
MacDonald et al Am J Cardiol 2016 Jul 29 (published ahead of print)
Trang 14Diagnosis: Prognosis
MacDonald et al Am J Cardiol 2016 Jul 29 (published ahead of print)
Death at 1 year HFPEF 15% vs HFREF 17%
OR 0.82 (0.57-1.18)(p=0.28)
Trang 15Diagnosis: Imaging
Su et al J Am Coll Cardiol Img
2014; 7(10): 991-997
Trang 16Diagnosis: Hemodynamics
ERJ 2009, 33, 1: 189-200,
http://mdnxs.com/topics-2/procedures-2/swan-ganz-catheter/
Trang 17Diagnosis: Hemodynamics
E/e’ and PCWP / LVEDP
Trang 18Diagnosis: Hemodynamics
Circulation 2000;102:1788-1794
Trang 19Diagnosis: Hemodynamics
A.E Huis in ’t Veld Neth Heart J 2016, 24: 244–251
Trang 20Maeder J Am Coll Cardiol 2010;56:855–63
Trang 21Maeder J Am Coll Cardiol 2010;56:855–63
Trang 22European Heart Journal – Cardiovascular Imaging (2016) 17, 106–113
E/e’ > 13
TR Vel > 2.8
Trang 23Diagnosis: Biomarkers
Eur J Heart Fail 2012 Dec;14(12):1338-47
Growth differentiation factor (GDF-15) ST-2
Trang 24Diagnosis: Biomarkers
J Am Coll Cardiol 2013; 61: 1498–506
Trang 25Ago and Sadoshima Circ Res 2006; 98: 294-297
Trang 26Eur J Heart Fail 2012 Dec;14(12):1338-47,
Eur J Heart Fail 2016, 18: 81 –88
Trang 27Eur J Heart Fail 2012 Dec;14(12):1338-47,
NT-proBNP/GDF-15/ST2/hsTNT
Trang 28Eur J Heart Fail 2016, 18: 81 –88
Trang 31Krum Nature Review: Cardiology 2015 Dec 12: 740
Trang 33Spironolactone
RALES N Engl J Med 1999; 341:709-717
Trang 34NEJM 2014, 370: 1383-92
TOPCAT (2014)
N = 3445 Follow up 3.3 years Primary Endpoint: MACE
Trang 35TOPCAT 2014
Trang 36TOPCAT subgroup 2015
CIRC 2015;131: 34-42
Russia / Georgia n = 1678 Younger
Less AF / DM More MI / Hospitalisation Lower baseline creatinine
Trang 37CIRC 2015;131: 34-42
Trang 39soluble Guanylate Cyclase - sGC
Circulation 2011; 123: 2263-2273
Trang 40JAMA 2015; 314(21): 2251-2262
Singapore
Singapore, Singapore, 119228 Singapore, Singapore, 169609 Singapore, Singapore, 308433
Singapore, Singapore, 768828
Trang 41SOCRATES
JAMA 2015; 314(21): 2251-2262
Trang 42SOCRATES Phase 2b
JAMA 2015; 314(21): 2251-2262
Vericiguat (BAY1021189)
Trang 43SOCRATES Phase 2b
JAMA 2015; 314(21): 2251-2262
Trang 44Vericiguat
https://clinicaltrials.gov/ct2/show/NCT02861534
Trang 45LCZ-696
PARADIGM-HF NEJM 2014; 371: 993-1004
Trang 46LCZ-696
https://clinicaltrials.gov/ct2/show/NCT01920711
Trang 47HFREF HFPEF
Aliskiren
(DRI)
ASTRONAUT JAMA 2013 Negative
Serelaxin RELAX-AHF Lancet 2013 Mortality
37% lower
Relax-AHF EHJ 2013 Negative
LCZ-696
(ARNI)
PARADIGM-HF NEJM 2014
Mortality 16% lower
PARAGON-HF ongoing ???
Vericiguat
Trang 48What’s New
Diagnosis – stress testing
Diagnosis – Biomarkers ST-2 / GDF-15 Treatment – ARNi / SCG agonist