Heart failure with borderline left ventricular systolic dysfunction: What's new in prognosis and management?
Disclosure
Advisory Board
Novartis, Boehringer Ingelheim, Bayer, Sanofi, Pfizer, Astra Zeneca
Principle Investigator
Novartis, Sanofi, Bayer, Astra Zeneca, Eli-Lilly, Amgen, Pfizer
Sponsorship (2014-2015 only)
Astra Zeneca, Bayer
All Honorariums donated to Department Research and Training Fund
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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 Consultant and Head of Department Department of Cardiology Khoo Teck Puat Hospital Disclosure Advisory Board Novartis, Boehringer Ingelheim, Bayer, Sanofi, Pfizer, Astra Zeneca Principle Investigator Novartis, Sanofi, Bayer, Astra Zeneca, Eli-Lilly, Amgen, Pfizer Sponsorship (2014-2015 only) Astra Zeneca, Bayer All Honorariums donated to Department Research and Training Fund Ejection Fraction not mentioned Diagnosis was based on 1. Low • Cardiac Index 2. High • PCWP (surrogate for LA / LVEDP) • Systemic Vascular Resistance Ejection Fraction not mentioned Diagnosis was based on 1. Clinical 1. Symptoms 2. Oedema 2. CXR Ejection Fraction < 45% used NELSON, N COHN, GORLIN CIRC 1975, 52: 408 Ejection Fraction < 30 % vs < 50% Heart Failure Preserved EF (HFPEF) Ziles N Engl J Med 2004;350:1953-9. Heart Failure Preserved EF (HFPEF) Ziles N Engl J Med 2004;350:1953-9. LVEDP ~ 5mmHg Heart Failure Preserved EF (HFPEF) Ziles N Engl J Med 2004;350:1953-9. LVEDP ~ 5mmHg LVEDP ~ 17mmHg Preserved EF Reduced EF Preserved versus Reduced Diagnosis: Prognosis Vasan et al Framingham Study JACC 1999, 331, 1948 Diagnosis: Prognosis MacDonald et al Am J Cardiol 2016 Jul 29 (published ahead of print) Diagnosis: Prognosis MacDonald et al Am J Cardiol 2016 Jul 29 (published ahead of print) Diagnosis: 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) Diagnosis: Imaging Su et al J Am Coll Cardiol Img 2014; 7(10): 991-997 Diagnosis: Hemodynamics ERJ 2009, 33, 1: 189-200, PCWP LA LVEDP Diagnosis: Hemodynamics E/e’ and PCWP / LVEDP Diagnosis: Hemodynamics Circulation. 2000;102:1788-1794. Diagnosis: Hemodynamics A.E. Huis in ’t Veld Neth Heart J 2016, 24: 244–251 Maeder J Am Coll Cardiol 2010;56:855–63 Maeder J Am Coll Cardiol 2010;56:855–63 European Heart Journal – Cardiovascular Imaging (2016) 17, 106–113 E/e’ > 13 TR Vel > 2.8 Diagnosis: Biomarkers Eur J Heart Fail 2012 Dec;14(12):1338-47. Growth differentiation factor (GDF-15) ST-2 Diagnosis: Biomarkers J Am Coll Cardiol 2013; 61: 1498–506 Ago and Sadoshima Circ Res 2006; 98: 294-297 Eur J Heart Fail 2012 Dec;14(12):1338-47, Eur J Heart Fail 2016, 18: 81 –88 Eur J Heart Fail 2012 Dec;14(12):1338-47, NT-proBNP/GDF-15/ST2/hsTNT Eur J Heart Fail 2016, 18: 81 –88 Eur J Heart Fail 2016, 18: 81 –88 What’s New Diagnosis Hemodynamics Biomarkers Management Spironolactone Soluble guanylyl cyclase Sacubitril Krum Nature Review: Cardiology 2015 Dec 12: 740 McMurray EHJ 2006, 27: 2257 CHARM-preserved (n=3023) PEP-CHF (n=850) I-PRESERVE (n=4133) Mean age (yr) 67 75 72 Women (%) 40 56 60 Mean LVEF (%) 54 64 59 NYHA I /II 0/61 75 0/21 NYHA III / IV 37/2 25 76/3 Ischemic / HTN 57/23 n/a 25/64 LVH (%) 15 23 Spironolactone RALES N Engl J Med 1999; 341:709-717 NEJM 2014, 370: 1383-92 TOPCAT (2014) N = 3445 Follow up 3.3 years Primary Endpoint: MACE TOPCAT 2014 TOPCAT subgroup 2015 CIRC 2015;131: 34-42 Russia / Georgia n = 1678 Younger Less AF / DM More MI / Hospitalisation Lower baseline creatinine CIRC 2015;131: 34-42 CIRC 2015;131: 34-42 soluble Guanylate Cyclase - sGC Circulation 2011; 123: 2263-2273 JAMA 2015; 314(21): 2251-2262. Singapore Singapore, Singapore, 119228 Singapore, Singapore, 169609 Singapore, Singapore, 308433 Singapore, Singapore, 768828 SOCRATES JAMA 2015; 314(21): 2251-2262. SOCRATES Phase 2b JAMA 2015; 314(21): 2251-2262. Vericiguat (BAY1021189) SOCRATES Phase 2b JAMA 2015; 314(21): 2251-2262. Vericiguat https://clinicaltrials.gov/ct2/show/NCT02861534 LCZ-696 PARADIGM-HF NEJM 2014; 371: 993-1004 LCZ-696 https://clinicaltrials.gov/ct2/show/NCT01920711 HFREF 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 (sGC) VICTORIA ??? VICTORIA ??? What’s New Diagnosis – stress testing Diagnosis – Biomarkers ST-2 / GDF-15 Treatment – ARNi / SCG agonist
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