Congestive Heart Failure: Preserved Ejection Fraction

KEY FEATURES

ESSENTIALS OF DIAGNOSIS

• Clinical presentation of congestive heart failure

• Preserved left ventricular systolic function

• Abnormal left ventricular diastolic function

GENERAL CONSIDERATIONS

• The prevalence of heart failure with preserved ejection fraction (HFpEF) has continued to rise, now accounting for approximately 50% of all heart failure cases

• The basic pathophysiologic problem is the inability of the left ventricle to fill at normal filling pressures

• This reduction in ventricular compliance can be due to hypertrophy, endocardial inflammation due to obesity and diabetes, infiltrative diseases such as amyloid, restriction from fibrosis such as radiation damage, or segmental fibrosis and hypertrophy from chronic ischemic heart disease

• Many patients with predominant diastolic left ventricular dysfunction have systolic dysfunction as well, but it is mild

• High atrial pressures are maintained in order to increase cardiac output

• Because diastolic left ventricular dysfunction has no specific treatment, it is important to detect reversible causes of heart failure with normal systolic function such as transient myocardial ischemia

• HFpEF phenotypes based on subgrouping of comorbidities (obesity, coronary artery disease, diabetes, atrial fibrillation) may offer pathway-specific management

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

• Dyspnea and fatigue with exertion

• Orthopnea

PHYSICAL EXAM FINDINGS

• Elevated jugular venous pressure, edema

• Pulmonary rales

• S₄

DIFFERENTIAL DIAGNOSIS

• Pulmonary hypertension

• Mitral valve disease

• Transient myocardial ischemia

• Volume overload

DIAGNOSTIC EVALUATION

ELECTROCARDIOGRAPHY

• Left ventricular and atrial hypertrophy is common

• Atrial tachyarrhythmias are common due to enlarged atrial size

IMAGING STUDIES

• Echocardiography:

  • – Normal or near-normal left ventricular systolic function (generally ejection fraction > 50%)

  • – Abnormal left ventricular diastolic function with elevated filling pressures on Doppler

  • – Left ventricular hypertrophy and left atrial enlargement are common

  • – The cause of the diastolic dysfunction may be identified, such as left ventricular hypertrophy, amyloid, or myocardial scarring

DIAGNOSTIC PROCEDURES

• Stress testing with echo or radionuclide perfusion imaging may be necessary to exclude myocardial ischemia

• Coronary angiography may be necessary to exclude coronary artery disease

• Myocardial biopsy may be necessary to diagnose infiltrative diseases (eg, amyloid)

TREATMENT

CARDIOLOGY REFERRAL

• Heart failure

• Abnormal left ventricular diastolic function

HOSPITALIZATION CRITERIA

• Pulmonary edema

• Suspected acute myocardial ischemia

• Rapid atrial fibrillation

MEDICATIONS

• Treatment of underlying condition that may be contributing to diastolic dysfunction, especially control of systemic hypertension and atrial fibrillation

• Diuretics for symptomatic relief

• Blocking the renin-angiotensin-aldosterone system has not been shown to be effective for reducing death and major cardiac events, but low-dose spironolactone may ...