Heart failure with preserved ejection fraction

Question 1

Signs of heart failure

Answer 1

• elevated JVP
• Third heart sound
• Cardiomegaly

Question 2

Symptoms of heart failure

Answer 2

• SOB
• Orthopnea
• PND
• Ankle swelling
• Reduced exercise tolerance

Question 3

Investigations used to diagnose heart failure

Answer 3

• BNP
• ECHO
• Evidence of cardiogenic, pulmonary of systemic congestion

Question 4

Classification of heart failure according to ejection fraction

Answer 4

• HF with reduced EF: HF + LVEF <40%
• HF with mildly reduced EF: HF + LVEF 41-49%
• HF with preserved EF: HF + LVEF >50%
• HF with improved EF: A 10% improvement in EF compared to baseline ECHO

Question 5

RFx for developing HFpEF

Answer 5

• Advanced age
• HTN
• Diabetes
• Obesity
• Prev MI

Question 6

Differences between HFpEF and heart failure

Answer 6

HFpEF
- Impaired ventricular relaxation
-Increased filling pressures
- Pressure overload

HF with reduced EF
- Concentric LVH remodelling
- LV dilatation
- Volume overload

Question 7

Diagnostic criteria for HFpEF

Answer 7

(i) The presence of symptoms and signs of HF
(ii) LV ejection fraction (LVEF) >50%
(iii) Exclusion of other pathologies that can mimic HFpEF
(iv) Evidence of increased LV filling pressures/DD/increased
left atrial volume and raised natriuretic peptides

Question 8

Differential diagnoses for HFpEF

Answer 8

• Coronary artery disease
• Hypertrophic cardiomyopathy
• Amyloid cardiomyopathy
• Pulm HTN
• Constrictive pericarditis

Question 9

Treatment for HFpEF

Answer 9

Pharmacological
- SGLT2 inhibitors (-flozins)
- Diuretics- furosemide, bumetanide
- ACEi/ ARB
- Spironolactone
- GLP1 agonists

Non-pharmacological
- Wt loss
- Exercise
- Pacing- theoretical, increase in HR to help with exercise

Question 10

Preoperative considerations for patients with HFpEF

Answer 10

• Assess functional capacity
• Consult cardiology for optimisation
• Optimise co-morbidites
• Prehab
• Medicine management- e.g. SGLT2 inhibitors

Question 10

Intraoperative considerations for patients with HFpEF

Answer 10

• Avoid tachycardia: shortens diastolic filling in a stiff heart
• Avoid fluid overload: high lt atrial pressures lead to pulm congestion and oedema
• Maintain sinus rhythm: difficult most pts have AF
• Maintain pre-load

Question 11

Postoperative considerations for patients with HFpEF

Answer 11

• Avoid sympathetic surge of extubation
• If neuraxial technique used often rapid movement of fluid back into vasculature as it resolves which can cause fluid overload
• Monitor for euglycaemic ketoacidosis if on SGLT2 inhib