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Prof. Walter Paulus
Apart from diastolic LV dysfunction, systolic LV dysfunction and pulmonary hypertension should also be considered important contributors to HFPEF as evident from the significant depression of longitudinal strain observed in the PARAMOUNT trial.
In contrast to Doppler evidence of diastolic LV dysfunction, left atrial enlargement seems to provide a more solid argument for predisposition to HFPEF.
F. Edelmann (Goettingen, Germany) further expanded on the importance of exercise. Lack of physical exercise predisposes people to development of HFPEF. In a randomised trial, which he coordinated, regular exercise reduced rest LV filling pressures and improved peak exercise oxygen consumption.
Pharmacological treatment of HFPEF was further expanded upon by J. McMurray (Glasgow, UK).He focused on the use of verapamil, mineralocorticoid antagonists, sildenafil and ivabradine. Remarkable differences showed up between natriuretic peptide levels and exercise performance in the different trials. In Aldo DHF, which investigated the use of spironolactone in HFPEF, natriuretic peptide levels were low and peak exercise tolerance relatively well preserved.
In contrast, in the RELAX study, which investigated the use of sildenafil in HFPEF, natriuretic peptide levels were high and peak exercise tolerance low. It remains unclear to what extent the unequal outcome of both trials (positive in Aldo DHF and neutral in RELAX), could be ascribed to the different characteristics of the patients included in both trials. Results of TOPCAT, which also investigates use of spironolactone in HFPEF, are eagerly awaited because this study apparently recruited a patient population with higher natriuretic peptide levels and low exercise tolerance.
Finally, B. Pieske (Graz, Austria) addressed future implementations of diagnostic HFPEF algorithms. The current diagnostic algorithm (Paulus et al. EHJ 2007) performed well in a group of patients with HFPEF in Graz, and was nicely related to patient outcome. He also suggested that systolic function indices could be explored, especially longitudinal strain. Moreover, biomarkers other than natriuretic peptides such as soluble ST2 , galectin and GDF15 could be of use. Finally, he proposed a scoring system similar to the one used in infective endocarditis, consisting of a summation of minor and major criteria. Diagnosis and treatment of HFPEF will probably remaining challenging for the years to come.
Session Title: Challenges in heart failure with preserved ejection fraction
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