Evaluation and management of patients with heart failure and preserved left ventricular ejection fraction

Drug Therapy for Acute and Chronic Heart Failure with Preserved Ejection Fraction with Hypertension: A State-of-the-Art Review

In this comprehensive state-of-the-art review, we provide an evidence-based analysis of current drug therapies for patients with heart failure with preserved ejection fraction (HFpEF) in the acute and chronic phases with concurrent hypertension. Additionally, we explore the latest developments and emerging evidence on the efficacy, safety, and clinical outcomes of common and novel drug treatments in the management of HFpEF with concurrent hypertension. During the acute phase of HFpEF, intravenous diuretics, mineralocorticoid receptor antagonists (MRAs), and vasodilators are pivotal, while in the chronic phase, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have proven effective in enhancing clinical outcomes. However, the use of calcium channel blockers in HFpEF with hypertension should be approached with caution, owing to their potential negative inotropic effects. We also explored emerging drug therapies for HFpEF, such as sodium-glucose co-transporter 2 (SGLT2) inhibitors, angiotensin receptor-neprilysin inhibitor (ARNI), soluble guanylate cyclase (sGC) stimulators, novel MRAs, and ivabradine. Notably, SGLT2 inhibitors have shown promise in reducing heart failure hospitalizations and cardiovascular mortality in patients with HFpEF, regardless of their diabetic status. Additionally, ARNI and sGC stimulators have demonstrated potential in improving symptoms, functional capacity, and quality of life. Nonetheless, additional research is necessary to pinpoint optimal treatment strategies for HFpEF with concurrent hypertension. Furthermore, long-term studies are essential to assess the durability and sustained benefits of emerging drug therapies. Identification of novel targets and mechanisms underlying HFpEF pathophysiology will pave the way for innovative drug development approaches in the management of HFpEF with concurrent hypertension.

Left Atrial Decompression With the HeartMate3 in Heart Failure With Preserved Ejection Fraction: Virtual Fitting and Hemodynamic Analysis

Effective treatment of heart failure with preserved ejection fraction (HFpEF) remains an unmet medical need. Although left atrial decompression using mechanical circulatory support devices was previously suggested, the heterogeneous HFpEF population and the lack of tailored devices have prevented the translation into clinical practice. This study aimed to evaluate the feasibility of left atrial decompression in HFpEF patients with a HeartMate 3 (HM3, Abbott Inc, Chicago, USA) in silico and in vitro . Anatomic compatibility of the HM3 pump was assessed by virtual device implantation into the left atrium through the left atrial appendage (LAA) and left atrial posterior wall (LAPW) of 10 HFpEF patients. Further, the efficacy of left atrial decompression was investigated experimentally in a hybrid mock loop, replicating the hemodynamics of an HFpEF phenotype at rest and exercise conditions. Virtual implantation without substantial intersection with surrounding tissues was accomplished through the LAA in 90% and 100% through the LAPW. Hemodynamic analysis in resting conditions demonstrated normalization of left atrial pressures without backflow at a pump speed of around 5400 rpm, whereas a range of 6400-7400 rpm was required during exercise. Therefore, left atrial decompression with the HM3 may be feasible in terms of anatomic compatibility and hemodynamic efficacy.

Association of Blood Pressure and Heart Rate Responses to Submaximal Exercise With Incident Heart Failure: The Framingham Heart Study

Background Exercise stress tests are conventionally performed to assess risk of coronary artery disease. Using the FHS (Framingham Heart Study) Offspring cohort, we related blood pressure (BP) and heart rate responses during and after submaximal exercise to the incidence of heart failure (HF). Methods and Results We evaluated Framingham Offspring Study participants (n=2066; mean age, 58 years; 53% women) who completed 2 stages of an exercise test (Bruce protocol) at their seventh examination (1998-2002). We measured pulse pressure, systolic BP, diastolic BP, and heart rate responses during stage 2 exercise (2.5 mph at 12% grade). We calculated the changes in systolic BP, diastolic BP, and heart rate from stage 2 to recovery 3 minutes after exercise. We used Cox proportional hazards regression to relate each standardized exercise variable (during stage 2, and at 3 minutes of recovery) individually to HF incidence, adjusting for standard risk factors. On follow-up (median, 16.8 years), 85 participants developed new-onset HF. Higher exercise diastolic BP was associated with higher HF with reduced ejection fraction (ejection fraction <50%) risk (hazard ratio [HR] per SD increment, 1.26; 95% CI, 1.01-1.59). Lower stage 2 pulse pressure and rapid postexercise recovery of heart rate and systolic BP were associated with higher HF with reduced ejection fraction risk (HR per SD increment, 0.73 [95% CI, 0.57-0.94]; 0.52 [95% CI, 0.35-0.76]; and 0.63 [95% CI, 0.47-0.84], respectively). BP and heart rate responses to submaximal exercise were not associated with risk of HF with preserved ejection fraction (ejection fraction ≥50%). Conclusions Accentuated diastolic BP during exercise with slower systolic BP and heart rate recovery after exercise are markers of HF with reduced ejection fraction risk.

Physical Therapist Clinical Practice Guideline for the Management of Individuals With Heart Failure

The American Physical Therapy Association (APTA), in conjunction with the Cardiovascular and Pulmonary Section of APTA, have commissioned the development of this clinical practice guideline to assist physical therapists in their clinical decision making when managing patients with heart failure. Physical therapists treat patients with varying degrees of impairments and limitations in activity and participation associated with heart failure pathology across the continuum of care. This document will guide physical therapist practice in the examination and treatment of patients with a known diagnosis of heart failure. The development of this clinical practice guideline followed a structured process and resulted in 9 key action statements to guide physical therapist practice. The level and quality of available evidence were graded based on specific criteria to determine the strength of each action statement. Clinical algorithms were developed to guide the physical therapist in appropriate clinical decision making. Physical therapists are encouraged to work collaboratively with other members of the health care team in implementing these action statements to improve the activity, participation, and quality of life in individuals with heart failure and reduce the incidence of heart failure-related re-admissions.

Effect of organic and inorganic nitrates on cerebrovascular pulsatile power transmission in patients with heart failure and preserved ejection fraction

OBJECTIVE

Increased penetration of pulsatile power to the brain has been implicated in the pathogenesis of age-related cognitive dysfunction and dementia, a common comorbidity in patients with heart failure and preserved ejection fraction (HFpEF). However, there is a lack of knowledge on the effects of organic and inorganic nitrates administration in this population on the power carried by pressure and flow waves traveling through the proximal aorta and penetrating the carotid artery into the brain microvasculature.

APPROACH

We assessed aortic and carotid hemodynamics non-invasively in two sub-studies: (1) at baseline and after administration of 0.4 mg of sublingual nitroglycerine (an organic nitrate; n  =  26); and (2) in a randomized controlled trial of placebo (PB) versus inorganic nitrate administration (beetroot-juice (BR), 12.9 mmol NO₃; n  =  16).

MAIN RESULTS

Wave and hydraulic power analysis demonstrated that NTG increased total hydraulic power (from 5.68% at baseline to 8.62%, P  =  0.001) and energy penetration (from 8.69% to 11.63%; P  =  0.01) from the aorta to the carotid, while inorganic nitrate administration did not induce significant changes in aortic and carotid wave power (power: 5.49%PB versus 6.25%BR, P  =  0.49; energy: 8.89%PB versus 10.65%BR, P  =  0.27).

SIGNIFICANCE

Organic nitrates, but not inorganic nitrates, increase the amount of hydraulic energy transmitted into the carotid artery in subjects with HFpEF. These findings may have implications for the adverse effect profiles of these agents (such as the differential incidence of headaches) and for the pulsatile hemodynamic stress of the brain microvasculature in this patient population.

Maximum daily 6 minutes of activity: an index of functional capacity derived from actigraphy and its application to older adults with heart failure

OBJECTIVES

To compare the correlation between the maximum 6 minutes of daily activity (M6min) and standard measures of functional capacity in older adults with heart failure (HF) with that in younger subjects and its prognostic utility.

DESIGN

Prospective, cohort study.

SETTING

Tertiary care, academic HF center.

PARTICIPANTS

Sixty, ambulatory, adults, New York Heart Association (NYHA) Class I to III, stratified into young (50.9 +/- 9.4) and older cohorts (76.8 +/- 8.0).

MEASUREMENTS

Correlation between M6min and measures of functional capacity (6-minute walk test; 6MWT) and peak oxygen consumption (VO(2)) according to cardiopulmonary exercise testing in a subset of subjects. Survival analysis was employed to evaluate the association between M6min and adverse events.

RESULTS

Adherence to actigraphy was high (90%) and did not differ according to age. The correlation between M6min and 6MWT was higher in subjects aged 65 and older than in those younger than 65 (correlation coefficient (r=0.702, P<.001 vs r=0.490, P=.002). M6min was also significantly associated with peak VO(2) (r=0.612, P=.006). During the study, 26 events occurred (2 deaths, 10 hospitalizations, 8 emergency department visits, and 6 intercurrent illnesses). The M6min was significantly associated with subsequent events (hazard ratio=2.728, 95% confidence interval=1.10-6.77, P=.03), independent of age, sex, ejection fraction, NYHA class, brain natriuretic peptide, and 6MWT.

CONCLUSION

The high adherence to actigraphy and association with standard measures of functional capacity and independent association with subsequent morbid events suggest that it may be useful for monitoring older adults with HF.

Atrial fibrillation in congestive heart failure

Atrial fibrillation (AF) and heart failure (HF) are common and interrelated conditions, each promoting the other, and both associated with increased mortality. HF leads to structural and electrical atrial remodeling, thus creating the basis for the development and perpetuation of AF; and AF may lead to hemodynamic deterioration and the development of tachycardia-mediated cardiomyopathy. Stroke prevention by antithrombotic therapy is crucial in patients with AF and HF. Of the 2 principal therapeutic strategies to treat AF, rate control and rhythm control, neither has been shown to be superior to the other in terms of survival, despite better survival in patients with sinus rhythm compared with those in AF. Antiarrhythmic drug toxicity and poor efficacy are concerns. Catheter ablation of AF can establish sinus rhythm without the risks of antiarrhythmic drug therapy, but has important procedural risks, and data from randomized trials showing a survival benefit of this treatment strategy are still lacking. In intractable cases, ablation of the atrioventricular junction and placement of a permanent pacemaker is a treatment alternative; and biventricular pacing may prevent or reduce the negative consequences of chronic right ventricular pacing.

Understanding heart failure with preserved ejection fraction: clinical importance and future outlook

Heart failure (HF) with preserved ejection fraction (HF-PEF) accounts for approximately one half of all HF patients admitted with acute decompensated HF and carries a significant morbidity and mortality burden. This condition, however, has been largely understudied because it is difficult to diagnose, and management guidelines are still being discussed. This article provides an overview of HF-PEF and its pathophysiology, diagnosis, and treatment, with a focus on clinical trials using renin-angiotensin-aldosterone system (RAAS) blockers. Inhibitors of the RAAS have been studied in HF-PEF to determine whether their benefits extend beyond blood pressure control. However, the 3 trials conducted to date (CHARM-Preserved, PEP-CHF, and I-PRESERVE) with candesartan, perindopril, and irbesartan, have failed to demonstrate significant morbidity and mortality benefits. Although no agent has proven statistically significant benefits in morbidity and mortality in HF-PEF, recent studies have added to the breadth of clinical data and understanding of the demographics of these patients.

The restoration of chronotropic competence in heart failure patients with normal ejection fraction (RESET) study: rationale and design

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is the predominant form of heart failure among the elderly and in women. However, there are few if any evidence-based therapeutic options for HFpEF. The chief complaint of HFpEF is reduced tolerance to physical exertion. Recent data revealed that 1 potential mechanism of exertional intolerance in HFpEF patients is inadequate chronotropic response. Although there is considerable evidence demonstrating the benefits of rate-adaptive pacing (RAP) provided from implantable cardiac devices in patients with an impaired chronotropic response, the effect of RAP in HFpEF is unknown.

METHODS AND RESULTS

The Restoration of Chronotropic CompEtence in Heart Failure PatientS with Normal Ejection FracTion (RESET) study is a prospective, multicenter, double-blind, randomized with stratification, study assessing the effect of RAP on peak oxygen consumption and quality of life. RAP therapy will be evaluated in a crossover paired fashion for each patient within each study stratum. Study strata are based on patient beta-blocker usage at time of enrollment. The study is powered to assess the impact of pacing independently in both strata.

CONCLUSIONS

The RESET study seeks to evaluate the potential benefit of RAP in patients with symptomatic mild to moderate HFpEF and chronotropic impairment. Study enrollment began in July 2008.

Heart failure with normal ejection fraction: consideration of mechanisms other than diastolic dysfunction

More than half of patients with heart failure (HF) have a normal ejection fraction (EF). These patients are typically elderly, are predominantly female, and have a high incidence of multiple comorbid conditions associated with development of ventricular hypertrophy and/or interstitial fibrosis. Thus, the cause of HF has been attributed to diastolic dysfunction. However, the same comorbidities may also impact myocardial systolic, ventricular, vascular, renal, and extracardiovascular properties in ways that can also contribute to symptoms of HF by way of mechanisms not related to diastolic dysfunction. Accordingly, the descriptive term HF with normal EF has been suggested as an alternative to the mechanistic term diastolic HF. In this article, we review the current understanding of nondiastolic mechanisms that may contribute to the HF with normal EF syndrome to highlight potential pathways for research that may lead to new targets for therapy.

Current understanding of heart failure with preserved ejection fraction

PURPOSE OF REVIEW

A substantial proportion of patients with heart failure have preserved ejection fraction. Though patients with preserved ejection fraction experience a substantial burden of morbidity and mortality, the understanding of heart failure pathophysiology in this group remains incomplete and evidence-based therapeutic options are limited.

RECENT FINDINGS

The prevalence of heart failure in patients with preserved ejection fraction is increasing and prognosis in this population remains poor despite modern medical therapy. Though diastolic dysfunction is typically present, increasing evidence suggests that extracardiac factors such as renal dysfunction and enhanced central aortic stiffness may play an important role in the development and progression of heart failure symptoms. Results of the first randomized, controlled clinical trials in this population suggest a possible therapeutic role for renin-angiotensin system blockade in reducing heart failure-associated morbidity, but there is still no evidence-supported strategy for reducing mortality in this population.

SUMMARY

Though the epidemiology and impact of heart failure with preserved ejection fraction are increasingly clear, consensus regarding pathophysiology and the optimal therapeutic approach is still lacking. Pending completion of additional therapeutic trials in this population, treatment remains largely empiric and focused on optimizing myocardial performance in diastole by control of blood pressure, restoration or maintenance of sinus rhythm, and relief of volume overload.