HFpEF — the state of play in cath lab assessment

The next speaker at the Cardiology on the Green conference was Prof Barry Borlaug, Professor of Medicine and Director of Circulatory Failure Research in the Department of Cardiovascular Medicine at the Mayo Clinic, who delivered a talk titled ‘Heart failure with preserved ejection fraction (HFpEF) — State of the art and cath lab assessment’.

Prof Borlaug spoke about invasive assessments in cardiology and stressed to the attendees that a normal BNP measurement does not exclude HFpEF. “It’s quite good for HFrEF or systolic HF, but even below 125pg/ml, 18 per cent of patients with invasively-proven HFpEF fall within this range — 20 per cent less than 200; 30 per cent less than 300,” he said, “so it’s really not a useful rule-out test.”

Prof Borlaug presented interactive case studies to the attendees and outlined how he and his team tried to develop a system to determine and prioritise which patients needed a catheterisation procedure, and explained how he and his colleagues devised what he called a “HFpEF score”. This involved around 500 patients with confirmed HFpEF and clear non-cardiac dyspnoea and all other clinical criteria, in order to define patients with HFpEF from those without it. Patients were then scored with points, depending on whether they were obese; had hypertension treated with two or more medications; presence of AF; PH on echocardiogram; age above 60 years; and elevated E/E ratio.

“Adding these scores up gives you a good probability of HFpEF,” he explained.

Prof Borlaug summarised: “HF is defined haemodynamically and if there is uncertainty, we need to take the patient to the cath lab — normal resting haemodynamics do not guarantee that they will be normal during exercise. Things that we look for normally in HF, such as BNP, E/E prime ratio, low peak vo2 — they are helpful if they are abnormal, but they do not exclude HF if they are normal, and you need to think about invasive assessment in those circumstances,” he continued.

“Invasive assessment has also provided new insights into the different pathophysiologic subtypes, such as obesity-related HFpEF and pulmonary vascular disease, and has identified some promising new treatment targets and approaches, such as pulmonary vasodilators, pericardiotomy and a number of other options.”

Transplantation

Following Dr Borlaug’s presentation, the meeting was again addressed by Dr Barry Boilson, who spoke on the topic of ‘Advanced HF in the US Midwest’.

“Transplant remains the gold-standard therapy for advanced HF,” he told the attendees.

“However, in the Midwest, we have a problem with long waiting times and limited donor availability, but outcomes with mechanical support really have been improving as the technology has been improving.

“But when patients are sent for transplant, timely referral and appropriate selection are key.”

Also speaking was Dr Briain MacNeill, Galway-based Consultant Cardiologist, who addressed the theme of ‘Antiplatelet Therapy’, and he was followed by a talk by Dr Mack Eleid, Interventional Cardiologist and Associate Professor of Medicine at the Mayo Clinic, who spoke on the topic of ‘TAVR — The Future of Aortic Valve Replacement?’

Delegates also heard from Dr Rob McBane, who has a dual appointment at the Mayo Clinic in the fields of haematology and cardiology, with a special interest in coagulation. Dr McBane delivered a talk on ‘Novel Oral Anticoagulants’. Also speaking was Prof Bill McEvoy, Professor of Preventive Cardiology at NUI Galway and Consultant Cardiologist at University Hospital Galway, who addressed the topic of ‘Hypertension in 2019 — Reconciling US vs EU Guidelines’, and Dr Scott Wright, Professor of Medicine and Consultant in Cardiology in the Coronary Care Unit at the Mayo Clinic College of Medicine, who spoke on ‘Controversies in Lipid Management’.

Also speaking was Dr Susan Connolly, Cardiology Specialist in the Western Health and Social Care Trust in Northern Ireland and lead for the newly-launched ‘Our Hearts and Minds’ transformation programme for cardiovascular health. Dr Connolly delivered a presentation on the theme of ‘CV Risk in the Under-40s’.