Heart Failure with Preserved Ejection Fraction
General
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
- 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