HEART FAILURE WITH PRESERVED EJECTION FRACTION Flashcards
What is diastolic dysfunction (DD)?
Defined as increased viscoelastic chamber stiffness, impaired ventricular relaxation, or a combination of both.
What conditions may accelerate the decline in left ventricular compliance associated with DD?
Hypertension, diabetes, and obesity.
Can diastolic dysfunction occur in the absence of systolic dysfunction?
Yes, DD can occur with or without systolic dysfunction.
What symptoms can diastolic dysfunction lead to?
Dyspnea, orthopnea, and bilateral lower extremity swelling.
What is heart failure with preserved ejection fraction (HFpEF)?
A condition where impaired relaxation leads to increased left ventricular filling pressures, promoting HF symptoms.
What is the prevalence of HFpEF in individuals with heart failure?
Approximately 50% of individuals with heart failure have HFpEF.
What is the projected cost of HFpEF to the U.S. healthcare system by 2030?
~$70 billion.
Who are the individuals at highest risk of HFpEF?
Older women.
What are some risk factors for HFpEF?
Hypertension, obesity, physical inactivity, coronary artery disease, and atrial fibrillation.
What is the in-hospital mortality rate for HFpEF?
Ranges from 2.4% to 4.9%.
What is the 5-year mortality rate after hospitalization for HFpEF?
Roughly 40%.
What are some pathophysiological mechanisms contributing to HFpEF?
Chronotropic incompetence, autonomic dysfunction, systemic and pulmonary vascular dysfunction, reduced nitric oxide availability, and RV dysfunction.
What can precipitate decompensated HFpEF?
Uncontrolled blood pressure, atrial fibrillation, nonadherence to diuretic therapy, high sodium intake, myocardial ischemia, sepsis, and acute renal dysfunction.
How is HFpEF diagnosed?
Based primarily on signs and symptoms, with criteria including LVEF ≥50% and elevated LV filling pressures.
What are first-line diagnostic tools for suspected HFpEF?
Echocardiography, natriuretic peptide levels, and objective assessment of functional capacity.
Which echocardiographic parameters are used to assess diastolic dysfunction?
Biplane LA maximum volume index, E/e9 ratio, early diastolic velocity at septal and lateral sides, and peak TR velocity.
What classification is used for diastolic dysfunction based on mitral velocities?
Grade I, Grade II, Grade III DD, and indeterminate diastolic function.
What is the annual death rate for HFpEF in the United States?
8% to 12%.
What are some characteristics of patients with HFpEF compared to healthy individuals?
Lower lean total body and leg mass, higher intramuscular fat content, lower type 1 muscle fibers, and lower capillary density.
What is the lifetime risk of developing HFpEF for non-Black individuals compared to Black individuals?
11.2% for non-Black vs. 7.7% for Black individuals.
True or False: Diastolic dysfunction is necessary for the diagnosis of HFpEF.
False.
What are some advanced testing methods for diagnosing HFpEF?
Cardiac MRI, technetium pyrophosphate scintigraphy scan, and endomyocardial biopsy.
What is the role of cardiac MRI in assessing diastolic function?
To derive parameters such as LV mass, LA size and function, and myocardial deformation.
What specific cardiac diseases require a different approach in management?
Atrial fibrillation, hypertrophic cardiomyopathy, group I, III, or IV pulmonary hypertension, moderate or severe mitral annular calcification, significant mitral valve disease
What parameters can be derived from cardiac MRI to assess diastolic function?
- LV mass
- LA size and function
- Mitral inflow and pulmonary venous velocity profiles
- Myocardial deformation
What is the purpose of diastolic stress testing?
To assess diastolic dysfunction in select clinical situations.
What measurements are captured during right heart catheterization?
- LV systolic pressure
- Minimal LV pressure
- LV end-diastolic pressure
- Mean LV diastolic pressures
What is the gold standard for assessing diastolic function?
Invasive assessment
How can LV filling pressures be estimated noninvasively?
- Mitral inflow (E) velocities
- Mitral annulus (e9) velocities assessed with Doppler and tissue Doppler echocardiography
True or False: E/e9 increases in patients with normal myocardium during exercise.
False
What are the average E/e’ values and e’ velocities indicating normal diastolic function?
- Average E/e’ >14
- Septal e’ velocity <7 cm/s
- Lateral e’ velocity <10 cm/s
- TR velocity >2.8 m/s
- LA volume index >34 mL/m2
What is the primary focus of the acute management of decompensated HFpEF?
- Volume management
- Blood pressure control
- Reversal of precipitating factors
What is the goal of diuresis in the treatment of decompensated HFpEF?
To achieve euvolemic status
What should be monitored during diuretic therapy?
- Renal function (creatinine, blood urea nitrogen)
- Electrolytes (sodium, potassium, magnesium)
- Clinical parameters (symptoms, jugular venous pressure, daily weights)
What is a recommended blood pressure target for patients with decompensated HFpEF?
Less than 130/80 mm Hg
What are some precipitating factors that need identification in decompensated HFpEF?
- Ischemia
- Atrial fibrillation
- Anemia
- Infection
- Infiltrative cardiomyopathy
What nonpharmacological therapies are recommended for patients with chronic HFpEF?
- Dietary sodium restriction (2–3 g daily)
- Daily home weight monitoring
- Medication compliance
- Regular follow-up
What risk factors are associated with greater morbidity and mortality in HFpEF?
- Obesity
- Diabetes
- Hypertension
What pharmacological therapies are recommended for patients with chronic HFpEF?
- Beta-blockers
- ACE inhibitors/ARBs
- Mineralocorticoid antagonists
- Angiotensin-neprilysin inhibitors
What are the Class I recommendations for the treatment of HFpEF?
- Systolic and diastolic blood pressure should be controlled
- Diuretics should be used for relief of symptoms due to volume overload
What is a potential benefit of treatment with sacubitril-valsartan in HFpEF patients?
Potential benefit in female participants or participants with an LVEF below 57%
What is a common treatment for rate control in patients with atrial fibrillation and HFpEF?
- Beta-blockers
- Nondihydropyridine calcium channel blockers
- Digoxin
What is the recommended approach if adequate diuresis cannot be achieved?
Ultrafiltration
