Diastolic Heart Failure: What Is It?

Dr Amresh Raina Discusses How Heart Failure And Pulmonary Hypertension ...

Amresh Raina, MD, is director of the Advanced Heart Failure and Pulmonary Hypertension Program at Allegheny General Hospital and the Allegheny Health Network in Pittsburgh, Pennsylvania.

Amresh Raina, MD, is director of the advanced heart failure and pulmonary hypertension program at Allegheny General Hospital and the Allegheny Health Network in Pittsburgh, Pennsylvania. He is board-certified in advanced heart failure, echocardiography (imaging of the right ventricle), and general cardiology.

Transcript

How do the pathophysiologies of heart failure and chronically elevated pulmonary pressure intersect?

That's a very interesting question. Pulmonary hypertension, first of all, is a broad term, saying that the pulmonary artery pressures—the pressures in the blood vessels of the lungs—are elevated, but doesn't really say why they're elevated. And so the first thing to note is that there are multiple different reasons and pathophysiologies at work in the development of pulmonary hypertension.

There are specific forms of pulmonary hypertension that are related to elevated resistance in the blood vessels of the lungs, and those are pulmonary arterial hypertension—we call that WHO [World Health Organization] Group 1, as well as chronic thromboembolic pulmonary hypertension, [and] that's WHO Group 4. Those are diseases that lead to elevation and resistance in the blood vessels of the lungs, narrowing and constriction of the blood vessels. That elevates the pulmonary artery pressures, but also causes the right side of the heart to have to work harder to overcome that resistance and those pressures. And that can lead to right-sided congestive heart failure, symptoms of shortness of breath, swelling in the lower extremities, etc.

However, there are other forms of congestive heart failure that can cause pulmonary hypertension. Patients who have left-sided congestive heart failure, whether that's due to lower left ventricular ejection fraction—what we call heart failure with reduced ejection fraction—or in patients who have heart failure symptoms but preserved left ventricular ejection fraction, both of those entities can cause elevation in pressures on the left side of the heart and that pressure can back up into the lungs and cause secondary pulmonary hypertension. That's a different group of pulmonary hypertension, which we call related to left heart disease or WHO Group 2.

So, pulmonary hypertension can be the disease in and of itself, impacting the right side of the heart, or it can be a manifestation of a left-sided heart problem.

Dr. Raina is a nationally renowned physician with expertise in the diagnostic evaluation and management of pulmonary hypertension. His particular interest is in advanced imaging of the right ventricle in pulmonary arterial hypertension. He has published extensively in this field, with numerous peer-reviewed manuscripts, abstracts, and book chapters. Dr. Raina was named one of Pittsburgh Magazine's "Best Doctors" in 2019.

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Patients Receiving Drug Therapy Before LVAD Implantation Have High Risk ...

Patients with left-sided heart failure who get implanted devices to improve the pumping of their hearts may be more likely to develop heart failure on the opposite side of their hearts if they are pre-treated with off-label selective vasodilator drugs, according to new research published in Circulation: Heart Failure, an American Heart Association journal.

Between 10% and 40% of patients who undergo left-ventricular assist device (LVAD) implantation for left-sided heart failure develop right-sided heart failure -- a complication that spells worse outcomes. To head off the complication, physicians sometimes prescribe preemptive treatment with off-label selective vasodilator drugs called phosphodiesterase-5 inhibitors (PDE5i). PDE5i drugs are currently approved for use to avoid right heart failure in patients with pulmonary arterial hypertension due to causes other than heart disease, which is a different patient group from the ones followed in this study.

PDE5i drugs dilate the pulmonary artery -- the large vessel that carries blood away from the heart's right side and into the lungs. A handful of small studies have shown a possible benefit to this off-label approach in some patients but affirmative data from large-scale studies have been lacking and the current study hopes to help close this gap.

An LVAD is a mechanical heart pump. It's placed inside a person's chest, where it helps the heart pump oxygen-rich blood throughout the body. Unlike an artificial heart transplant, LVADs do not replace the heart. LVADs help the heart do its job.

The findings of the new study -- the largest analysis to date to assess the utility of this approach -- call the preemptive treatment with PDE5i drugs into question.

We found no benefit of this therapy in patients receiving LVAD devices, including patients with pulmonary vascular disease or right ventricular dysfunction -- the very patients who might be expected to benefit most. Our findings should give pause to clinicians considering this therapy, and we would caution against routine use of these therapies prior to LVAD surgery."

Michael Kiernan, M.D., M.S., Study Senior Investigator, Cardiologist, Tufts Medical Center and Assistant Professor of Medicine at Tufts University School of Medicine in Boston

The results are based on analysis of 11,544 U.S. LVAD recipients who underwent implantation between 2012 and 2017. Of all device recipients, 1,199 (10%) received pre-implantation treatment with PDE5i drugs which target the pulmonary artery to reduce the pressure in the heart's right ventricle. Overall, 24% of all patients who got LVAD implants developed right-sided heart failure, but the group that got pre-implantation drugs did so at higher rates. To minimize the possible effects of other factors that could bias the outcomes, the researchers matched 1,177patients treated with PDE5i drugs to group of 1,177 patients who did not receive such preventive therapy but were otherwise similar to the pre-treated group in terms of disease severity, age and the presence of other diseases that could affect outcome and health status.

Compared with those who did not get drug therapy, the group that received vasodilator drugs before LVAD implantation were 31% more likely to develop right-sided heart failure (29% for those treated, compared with 24% among those who did not receive pre-treatment). Additionally, the relative risk of bleeding within a week of LVAD surgery was 46% higher in patients receiving PDE5i therapy (12% of patients receiving therapy versus 8% of those not receiving this therapy), the analysis showed.

Source:

American Heart Association

Journal reference:

Gulati, G. Et al. (2019) Preimplant Phosphodiesterase-5 Inhibitor Use Is Associated With Higher Rates of Severe Early Right Heart Failure After Left Ventricular Assist Device Implantation. Circulation: Heart Failure. Doi. Org/ 10. 1161/ CIRCHEARTFAILURE. 118. 005537.

New Guidelines Recommend Earlier Detection And Treatment Of Pulmonary ...

Earlier detection of pulmonary hypertension in the community and expedited referral of high-risk or complex patients are recommended in the European Society of Cardiology (ESC) and European Respiratory Society (ERS) Guidelines for the diagnosis and treatment of pulmonary hypertension, published online today in European Heart Journal and the European Respiratory Journal.

The diagnosis of pulmonary hypertension, and thus initiation of appropriate management, is often substantially delayed. In young patients, frequently women, delays are often due to disbelief of severe illness in an otherwise healthy looking young individual. In older patients, co-existing conditions (such as hypertension, obesity, or cardiopulmonary diseases) may be blamed for the symptoms and pulmonary hypertension is missed. Patients with shortness of breath should seek medical help, and if the GP, cardiologist or pulmonologist cannot identify an appropriate reason, referral to an expert pulmonary hypertension centre is indicated."

Professor Stephan Rosenkranz, guidelines task force ESC chairperson, University Hospital Cologne, Germany

Pulmonary hypertension affects approximately 1% of the global population, and up to 10% of individuals over 65 years of age. It refers to high blood pressure in the lung circulation and differs from "hypertension" which is high blood pressure in the arteries supplying the rest of the body. People with the condition have thick, stiff pulmonary arteries which make the right side of the heart constantly work harder to push blood through, ultimately causing right heart failure. Pulmonary hypertension is a severe condition associated with substantially reduced life expectancy, if not successfully treated. Recent studies have shown that even moderately elevated pulmonary artery pressure or pulmonary vascular resistance are associated with increased mortality. This is why haemodynamic definitions had to be updated.

There are no specific symptoms, but patients usually suffer from progressive shortness of breath on exertion and reduced ability to exercise. Climbing stairs can be difficult. Many patients experience chronic fatigue, and fluid retention can occur as a result of impaired right heart function. Other symptoms include chest pain, dizziness and fainting, particularly in those with advanced right heart failure.

Guidelines task force ERS chairperson Professor Marion Delcroix of the University Hospitals of Leuven, Belgium said: "Being diagnosed with pulmonary hypertension, often after a considerable delay, and feeling physically limited has a tremendous psychological, emotional, and social impact on patients and their families. Psychosocial support is recommended in patients with pulmonary arterial hypertension (PAH), who often develop depression and anxiety and have to cut back on work."

Pulmonary hypertension is divided into five main groups based on the cause: 1) PAH, which is a distinct pulmonary vascular disease; 2) pulmonary hypertension associated with left heart disease; 3) pulmonary hypertension associated with chronic lung disease; 4) chronic thromboembolic pulmonary hypertension (CTEPH) due to recurrent blood clots in the lungs; and 5) pulmonary hypertension with unclear and/or multifactorial causes.

The guidelines cover the whole spectrum of pulmonary hypertension with an emphasis on diagnosing and treating PAH and CTEPH. For PAH, early diagnosis and initiation of treatment are key. Treatment options have improved within the last 15 years and three drug classes are currently approved. Most patients should receive a combination of at least two medications. Treatment decisions should be guided by the risk assessment strategy outlined in the document. Immunisation of patients with PAH against COVID-19, influenza, and pneumococcal disease is recommended.

In women with PAH, pregnancy can be associated with a substantial risk of maternal complications or even maternal death, especially when PAH is not well controlled with medical therapy. Therefore, it is recommended that women of childbearing potential with PAH are counselled at the time of diagnosis about the risks and uncertainties associated with becoming pregnant; this should include advice against becoming pregnant, and referral for psychological support where needed.

There are three options for treating CTEPH, which may be used alone or in combination. Pulmonary endarterectomy is the surgical removal of thromboembolic lesions from the pulmonary arteries and is the preferred strategy in eligible patients. Balloon pulmonary angioplasty is indicated in some patients unsuitable for surgery or who have persistent or recurrent pulmonary hypertension after surgery. During this procedure, a balloon is temporarily inserted into the pulmonary arteries using a catheter then inflated to move thromboembolic lesions and restore blood flow. The third treatment option is medication. Individual treatment strategies should be discussed in high volume centers with multidisciplinary teams.

Multidisciplinary input is central to the management of pulmonary hypertension. This is because a number of conditions can cause pulmonary hypertension, with left heart disease and chronic lung disease being the most frequent underlying causes. In addition, other conditions such as connective tissue disease, liver disease, human immunodeficiency virus (HIV) infection and congenital heart disease may cause PAH. Finally, a variety of imaging techniques, including computed tomography, cardiovascular magnetic resonance and echocardiography, are required to detect lung disease and chronic or recurrent pulmonary embolism, and to monitor right heart structure and function.

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