Diagnosis and management of heart failure with preserved ejection fraction: 10 key lessons

Abstract

Heart failure with preserved ejection fraction (HFpEF) is a common clinical syndrome associated with high rates of morbidity and mortality. Due to the lack of evidence-based therapies and increasing prevalence of HFpEF, clinicians are often confronted with these patients and yet have little guidance on how to effectively diagnose and manage them. Here we offer 10 key lessons to assist with the care of patients with HFpEF: (1) Know the difference between diastolic dysfunction, diastolic heart failure, and HFpEF; (2) diagnosing HFpEF is challenging, so be thorough and consider invasive hemodynamic testing to confirm the diagnosis; (3) a normal B-type natriuretic peptide does not exclude the diagnosis of HFpEF; (4) elevated pulmonary artery systolic pressure on echocardiography in the presence of a normal ejection fraction should prompt consideration of HFpEF; (5) use dynamic testing in evaluating the possibility of HFpEF in patients with unexplained dyspnea or exercise tolerance; (6) all patients with HFpEF should be systematically evaluated for the presence of coronary artery disease; (7) use targeted treatment for HFpEF patients based on their phenotypic classification; (8) treat HFpEF patients now by treating their comorbidities; (9) understand the importance of heart rate in HFpEF- lower is not always better; and (10) do not forget to consider rare diseases ("zebras") as causes for HFpEF when evaluating and treating patients. Taken together, these 10 key lessons can help clinicians care for challenging patients with HFpEF while we eagerly await the results of ongoing HFpEF clinical trials and observational studies.

Fig. (1)

Differentiation of diastolic dysfunction, diastolic heart failure, and heart failure with preserved ejection fraction. Abbreviations: DD—diastolic dysfunction; DHF—diastolic heart failure; HFpEF—heart failure with preserved ejection fraction; LV—left ventricular; LVEF—left ventricular ejection fraction.

Fig. (2)

Systematic diagnosis and treatment algorithm for heart failure and preserved ejection fraction (HFpEF), with specific criteria for diagnosis of coronary artery disease in HFpEF. Modified with permission from Shah SJ, Current Treatment Options in Cardiovascular Medicine, 2010; 12: 58-75. ACE—angiotensinconverting enzyme; ACS—acute coronary syndrome; ARB—angiotensin receptor blocker; BP—blood pressure; CABG—coronary artery bypass grafting; CAD—coronary artery disease; CI—chronotropic incompetence; CKD—chronic kidney disease; HF—heart failure; LV— left ventricular; LVEF—left ventricular ejection fraction; MI—myocardial infarction; PCI—percutaneous coronary intervention.

Fig. (3)

Doppler and tissue Doppler tracings from a 50-year-old patient with dyspnea, exercise intolerance, and preserved left ventricular ejection fraction. Panel A = Doppler imaging of mitral inflow; Panel B = tissue Doppler imaging of the septal mitral annulus. The high E velocity, high E/A ratio, short E deceleration time, and severely reduced tissue Doppler e’ and a’ velocities all point to severe (Grade 3) diastolic dysfunction. The presence of severe diastolic dysfunction with severely reduced e’ and a’ tissue Doppler velocities is highly indicative of an underlying cardiomyopathy (restrictive or infiltrative) in a relatively young patient with preserved left ventricular ejection fraction and no evidence of severe coronary disease or end-stage renal disease. This particular patient had symptoms for 2 years and had seen multiple cardiologists prior to the diagnosis of HFpEF due to biopsy-proven cardiac AL amyloidosis. She underwent chemotherapy followed by autologous stem cell transplantation and has been free of heart failure symptoms or evidence of primary AL amyloid recurrence for 5 years.