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Heart Failure with Preserved Ejection Fraction

General

  • 50% of HF cases

Physiology

  • LV diastolic dysfunction due to impaired relaxation w/EF >50%
  • Impaired Diastolic Filling, Decreased compliance
  • Decrease in SV and Increase in EDP
  • Significantly Increased LVEDP associated with Decrease in LVEDV
    • Increased afterload, increased LV thickness, decreased LV size, decreased Compliance – Decrease in Ventricular distensibility that impairs ventricular filling during diastole (EF ≥50)
    • Decreased LV Compliance, Decreased Lusitropy
  • Normal CO w/ increased LVEDV/RVEDP, tachycardia, S4
    • Increased venous hydrostatic pressure
    • Recurrent pulmonary flash edema
    • 2/2 hypertensive cardiac remodeling (LVH) with left atrial dilation, orthopnea, and elevated BNP
      • Mcly due to myocardial hypertrophy
      • RF: Chronic hypertension (concentric LVH), Obesity & sedentary lifestyle (myocardial interstitial fibrosis), CAD & related RF (T2DM)
  • Commonly due to
    • Pericardial Tamponade, Constrictive Pericarditis, Restrictive or Hypertrophic Cardiomyopathies
  • 1) Hypertension w/Left Ventricular Hypertrophy (90%)
    • Chronic Hypertension (Concentric LV Hypertrophy)
    • Primary (HCM), Secondary (Hypertension), Age, Fibrosis
    • LVH shows Severe dip in V1 and rise in V6
  • 2) Restrictive Cardiomyopathy (<9%)
    • Amyloid/Sarcoid, Hemochromatosis
    • Obesity/Sedentary lifestyle (myocardial interstitial fibrosis)
    • Preserved systolic dysfunction, bi-atrial dilation, pulmonary hypertension in a pt with refractory HF
    • Kussmaul’s sign
      • Lack of typical inspiratory decline in CVP
      • Associated with an S3

Mortality

  • Due to progressive HF and arrhythmias
  • 5-year rate of 36%
  • 10-year rate of 63%
    • Treatment
      • Eval for Transplant w/Advanced HF specialist

Symptoms

  • Exertional dyspnea
  • Paroxysmal nocturnal dyspnea
  • Orthopnea

Exam

  • S3
  • Elevated CVP
  • Crackles
  • Peripheral Edema

Diagnosis

  • A Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure With Preserved Ejection Fraction
  • H2pEF risk score
    • Assesses likelihood of HFpEF and is used to discriminate cardiac vs. non-cardiac causes of dyspnea
    • Obesity (2 points), Afib (3 points), age >60 (1 point), 2 Antihypertensives (1 point), Echo E/e’ ratio >9 (1 point) and Echo PAS pressure >35 (1 point)
  • Echo
    • Normal LV cavity size, increased LV wall thickness, LAE, abnormal diastolic function, elevated PAS pressure >35
  • BNP may be normal in obese or only exertional symptoms

Prognosis

  • Cause of Death (broader than HFrEF):
    • Cardiovascular
      • Worsening HF (RHF, Restrictive cardiomyopathy)
      • Sudden Death (Non-arrhythmic, Tachycardia, Bradycardia)
      • Myocardial Infarction
      • Vascular (Aortic Aneurysm, PE)
      • Cerebrovascular (Intracranial hemorrhage, Stroke)
    • Non-Cardiovascular
      • Renal (ESRD, renal venous congestion)
      • Resp (Failure, pulmonary hypertension, COPD)
      • Infection/sepsis
    • Multisystem (Organ failure)

Management

  • Diuresis
    • Caution in diastolic HF w/diuretics
  • Afterload reduction as needed
    • Reduce hospitalization
      • MRAs and SGLT-2s
    • ACEI/ARB = no mortality benefit
  • BP control
  • Treat exacerbating conditions (CAD, OSA, Afib)
  • Exercise training/cardiac rehabilitation
    • Improves functional capacity and overall quality of life