Novel non-pharmacological therapy to modulate the autonomic tone in patients with heart failure with pulmonary hypertension

The up-date of ESC Guidelines on the management of patients with heart failure was published last year. The beneficial effect of a new group of drugs (flozins, sacubitril/valsartan - ARNI) in patients with heart failure was pointed out. These drugs not only prevent the onset of heart failure but also reduce HF hospitalization rate and in patients with reduced left ventricular ejection fraction decrease risk of cardiovascular death and in case of empagliflozin, dapagliflozin or sacubitril/valsartan also total mortality. These latter medicines reduce also the likelihood of sudden cardiac death. ARNI reduce the number of appropriate ICD shocks, the incidence of non-sustained VT, premature ventricular contractions, and increase percentage of biventricular pacing in cardiac resynchronization recipients.

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PROCEDURE IN PATIENTS WITH HEART FAILURE (UPDATE 2019) – NON-PHARMACOLOGICAL THERAPY

In a good rythm ◽

10.5604/01.3001.0014.0499 ◽

2020 ◽

Vol 4 (53) ◽

pp. 19-22

Author(s):

Przemysław Mitkowski

Keyword(s):

Heart Failure ◽

Meta Analysis ◽

Pharmacological Therapy ◽

Functional Mitral Regurgitation ◽

Pharmacological Management ◽

Device Implantation ◽

Patients With Heart Failure ◽

Life Threatening ◽

Treatment Analysis ◽

High Level

Up-date of ESC Guidelines on management of patients with heart failure was published last year. Beside topics related to pharmacological treatment one can find also chapters dedicated to non-pharmacological management. In the field of ICD therapy Authors propose one may consider not to implant the device in patients over 70 years old, especially when they suffer from advanced heart failure and life-threatening comorbidities. It is in contra with meta-analysis presented after results of DANISH trial has been published, which underlined benefits of ICD treatment in such patients. Moreover in patients randomized to treatment without ICD almost 60% received CRTP. It is also important that 24 patients randomized to no-ICD group finally received ICD because of appearance of life-threatening ventricular arrhythmia. In such situation additional on-treatment analysis would be beneficial. One can get an impression that pulmonary vein ablation in patients with heart failure and atrial fibrillation achieve enough high level of recommendation despite favourable results of CASTLE-AF and on-treatment analysis of CABANA trials. Analysis of data according to received treatment seemed to be beneficial especially when the percentage of crossover is significant. Functional mitral regurgitation should be managed after meaningful analysis of each case and referral to MitraClip implantation should be based on the protocol of COAPT trial which proves benefits of a such device implantation.

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Abstract 19944: Targeted Therapy of Pulmonary Hypertension in Patients With Heart Failure and Preserved Ejection Fraction: Safety and Efficacy in Comparison to IPAH in Compera

Circulation ◽

10.1161/circ.132.suppl_3.19944 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Stephan Rosenkranz ◽

Marius M Hoeper ◽

Doerte Huscher ◽

David Pittrow ◽

Christian F Opitz

Keyword(s):

Risk Factors ◽

Heart Failure ◽

Pulmonary Hypertension ◽

Ejection Fraction ◽

Preserved Ejection Fraction ◽

Evidence Based Treatment ◽

Patients With Heart Failure ◽

Venous Oxygen Saturation ◽

Initial Ph ◽

Pulmonary Arterial

Background: While targeted therapies are available for idiopathic pulmonary arterial hypertension (IPAH), evidence based treatment recommendations for pulmonary hypertension (PH) associated with heart failure and preserved ejection fraction (HFpEF) are lacking. Methods and Results: Out of 5,935 patients in the prospective COMPERA registry, we analyzed patients with “typical” IPAH (n=421, ≤2 of the following risk factors: BMI >30 kg/m2, hypertension, CAD, diabetes and atrial fibrillation at the time of diagnosis), “atypical” IPAH (n=139, >2 risk factors) or PH-HFpEF (n=226) who received targeted PH therapies. Patients with PH-HFpEF, when compared to “typical” and “atypical” IPAH were older (73±8 vs. 62±17 and 71±9 years), had a higher BMI (30 vs. 26 and 32 kg/m2), and more comorbidities (98% vs. 73% and 100%, all p<0.001), respectively. However, mean PAP (46±9 vs. 47±13 and 44±11 mmHg), cardiac index (2.2±0.7 vs. 2,3±0,8 and 2,2±0,8 l/min), and mixed venous oxygen saturation (62±7 vs. 62±10 and 63±9%, all ns) were almost identical. As compared to “typical” and “atypical” IPAH, PH-HFpEF patients had a higher PAWP (20±4 vs. 9±3 and 10±4 mmHg), resulting in a lower calculated PVR (559±270 vs. 861±477 and 784±844 dyn.s.cm-5). Survival at 1, 2 and 3 years post diagnosis was not different between groups. PDE-5 inhibitors were the most common form of initial PH treatment in PH-HFpEF (94%), and combination therapy was less common compared to “typical” or “atypical” IPAH at 1 year (7% vs. 44% and 26%). All 3 groups responded to targeted PH therapies at 12 months, while treatment effects were less pronounced in PH-HFpEF: Compared to baseline, the median increase of the 6MWD at 1 year was 29, 50, and 60 m, respectively. Treatment discontinuations occurred more frequently in patients with PH-HFpEF than in IPAH, either because of side effects or lack of improvement. Conclusions: Despite almost identical alterations of pulmonary artery pressure and cardiac output, patients with PH-HFpEF differed with respect to age, comorbidities and certain hemodynamic features when compared to “typical” or “atypical” IPAH. All groups responded to targeted PH therapy, however tolerability and efficacy of PH drugs were reduced in patients with PH-HFpEF while survival was not different.

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New Definition of Pulmonary Hypertension in Patients with Heart Failure with Preserved Ejection Fraction

American Journal of Respiratory and Critical Care Medicine ◽

10.1164/rccm.201901-0148le ◽

2019 ◽

Vol 200 (3) ◽

pp. 386-388 ◽

Cited By ~ 5

Author(s):

Taiki Nishihara ◽

Eiichiro Yamamoto ◽

Takanori Tokitsu ◽

Daisuke Sueta ◽

Koichiro Fujisue ◽

...

Keyword(s):

Heart Failure ◽

Pulmonary Hypertension ◽

Ejection Fraction ◽

Preserved Ejection Fraction ◽

Patients With Heart Failure ◽

Definition Of

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Hemodynamic Effects of Pulmonary Arterial Hypertension-Specific Therapy in Patients With Heart Failure With Preserved Ejection Fraction and With Combined Post- and Precapillay Pulmonary Hypertension

Journal of Cardiac Failure ◽

10.1016/j.cardfail.2019.07.547 ◽

2020 ◽

Vol 26 (1) ◽

pp. 26-34 ◽

Cited By ~ 1

Author(s):

Anna E. Huis in’t Veld ◽

Frank P.T. Oosterveer ◽

Frances S. De man ◽

J. TIM Marcus ◽

Esther J. Nossent ◽

...

Keyword(s):

Heart Failure ◽

Pulmonary Hypertension ◽

Pulmonary Arterial Hypertension ◽

Ejection Fraction ◽

Arterial Hypertension ◽

Preserved Ejection Fraction ◽

Hemodynamic Effects ◽

Specific Therapy ◽

Patients With Heart Failure ◽

Pulmonary Arterial

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1409Use of phenomapping to determine response of treatment by sacubitril/valsartan in patients with heart failure with reduced ejection fraction

European Heart Journal ◽

10.1093/eurheartj/ehz748.0057 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

M Godet ◽

O Raitiere ◽

H Chopra ◽

P Guignant ◽

C Fauvel ◽

...

Keyword(s):

Heart Failure ◽

Pulmonary Hypertension ◽

Ejection Fraction ◽

Left Ventricular ◽

Heat Map ◽

Reduced Ejection Fraction ◽

Patients With Heart Failure ◽

Group 3 ◽

Group 2 ◽

Group 1

Abstract Background Treatment by sacubitril/valsartan decreases mortality, improves KCCQ score and ejection fraction in patients with heart failure with reduced ejection fraction (HF REF), but there is currently no data to predict response to treatment. Purpose The purpose of our work was to assess whether unbiased clustering analysis, using dense phenotypic data, could identify phenotypically distinct HF-REF subtypes with good or no response after 6 months of sacubitril/valsartan administration. Methods A total of 78 patients in NYHA functional class 2–3 and treated by ACE inhibitor or AAR2, were prospectively assigned to equimolar sacubitril/valsartan replacement. We collected demographic, clinical, biological and imaging continuous variables. Phenotypic domains were imputed with 5 eigenvectors for missing value, then filtered if the Pearson correlation coefficient was >0.6 and standardized to mean±SD of 0±1. Thereafter, we used agglomerative hierarchical clustering for grouping phenotypic variables and patients, then generate a heat map (figure 1). Subsequently, participants were categorized using Penalized Model-Based Clustering. P<0,05 was considered significant. Results Mean age was 60.4±13.4 yo and 79.0% patients were males. Mean ejection fraction was 29.3±7.0%. Overall, 16 phenotypic domains were isolated (figure 1) and 3 phenogroups were identified (Table 1). Phenogroup 1 was remarkable by isolated left ventricular involvement (LVTDD 64.3±5.9mm vs 73.9±8.7 in group 2 and 63.8±5.7 in group3, p<0.001) with moderate diastolic dysfunction (DD), no mitral regurgitation (MR) and no pulmonary hypertension (PH). Phenogroups 2 and 3 corresponded to patients with severe PH (TRMV: 2.93±0.47m/s in group 2 and 3.15±0.61m/s in groupe 3 vs 2.16±0.32m/s in group 1), related to severe DD (phenogroup 2) or MR (phenogroup 3). In both phenogroups, the left atrium was significantly enlarged and the right ventricle was remodeled, compared with phenogroup 1. Despite more severe remodeling and more compromised hemodynamic in phenogroups 2 and 3, the echocardiographic response to sacubitril/valsartan was comparable in all groups with similar improvement of EF and reduction of cardiac chambers dimensions (response of treatment, defined by improvement of FE +15% and/or decreased of indexed left ventricule diastolic volume −15% = group 2: 22 (76%); group 3: 18 (60%); group 1: 9 (50%); p=0.17; OR group 2 vs 1: OR=3.14; IC95% [0.9–11.03]; p=0.074; OR group 3 vs 1: OR=1.5; IC95% [0.46–4.87]; p=0.5)). The clinical response was even better in phenogroups 2 and 3 (Group 2: 19 (66%); group 3: 21 (78%) vs group 1: 9 (50%); p=0.05). Heat map Conclusion HF-REF patients with severe diastolic dysfunction, significant mitral regurgitation and elevated pulmonary hypertension by echocardiographic had similar reverse remodeling but better clinical improvement than patients with isolated left ventricular systolic dysfunction.

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