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Heart Failure with Preserved Ejection Fraction

General

o 50% of HF cases

Physiology

o LV diastolic dysfunction due to impaired relaxation w/EF >50% o Impaired Diastolic Filling, Decreased compliance  The pathophysiology of heart failure with preserved ejection fraction • https://pubmed.ncbi.nlm.nih.gov/24958077/ o Decrease in SV and Increase in EDP o 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 o 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) o Commonly due to  Pericardial Tamponade, Constrictive Pericarditis, Restrictive or Hypertrophic Cardiomyopathies o 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 o 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 arrythmias • 5-year rate of 36% • 10-year rate of 63%

  • Treatment • Eval for Transplant w/Advanced HF specialist

Symptoms

o Exertional dyspnea o Paroxysmal nocturnal dyspnea o Orthopnea

Exam

o S3 o Elevated CVP o Crackles o Peripheral Edema

Diagnosis

o A Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure With Preserved Ejection Fraction  https://pubmed.ncbi.nlm.nih.gov/29792299/ o H2pEF risk score  Assesses likelihood of HFpEF and is used to discriminate cardiac vs. noncardiac 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) o Echo  Normal LV cavity size, increased LV wall thickness, LAE, abnormal diastolic function, elevated PAS pressure >35 o BNP may be normal in obese or only exertional symptoms

Prognosis

o Cause of Death (broader than HFrEF):  Cardiovascular • Worsening HF (RHF, Restrictive cardiomyopathy) • Sudden Death (Non-arrhythmic, Tachy, Brady) • 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

o Diuresis  Caution in diastolic HF w/diuretics o Afterload reduction as needed  Reduce hospitalization • MRAs and SGLT2s  ACEI/ARB = no mortality benefit o BP control o Treat exacerbating conditions (CAD, OSA, Afib) o Exercise training/cardiac rehabilitation  Improves functional capacity and overall quality of life