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© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
in the clinic
Heart Failure With
Preserved Ejection
Fraction
(Diastolic Dysfunction)
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
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© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What is the difference between HFpEF,
diastolic dysfunction, and diastolic HF?
 Heart failure with preserved ejection fraction (HFpEF)
 Preferred term (ACC/AHA)
 Most often have abnormalities in diastolic function
(non-diastolic abnormalities in CV function also)
 Diastolic heart failure / Diastolic dysfunction
 Other common terms for HFpEF but less specific
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What’s the difference between HFpEF & HFrEF?
 Left ventricle doesn’t dilate in HFpEF
 Some treatments for HFrEF aren’t effective in HFpEF
 HFpEF:
 Older and more often female
 Higher frequency of hypertension; lower CAD
 Prevalence HFpEF rising 1% / yr relative to HFrEF
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
HFpEF is not “benign”
 Similar functional decline, hospital readmission rates,
economic costs as HFrEF
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What are the risk factors for HFpEF?
 For HF in general
 Age
 Hypertension
 Obesity
 Dyslipidemia
 Insulin resistance
 For HFpEF
 Older, more hypertensive, and higher prevalence of AF
(than in HFrEF)
 CAD prevalence comparatively lower
 More common in women (by 2:1)
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Are any interventions effective for primary
prevention of HFpEF?
 Control hypertension
 Main factor in development and progression
 Lower systolic & diastolic according to guidelines
 Treat hyperlipidemia and hyperglycemia
 Reduces risk for HFpEF and HFrEF
 Encourage smoking cessation, exercise, healthy diet
 Moderate alcohol consumption among patients who drink
 Weight reduction can prevent diabetes, AF, obstructive
sleep apnea, hypertension
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
CLINICAL BOTTOM LINE: Prevention…
 Reduce risk for HF
 Reduce systolic & diastolic BP <140/90 mm Hg (<130/80 mm Hg
if htn + diabetes or renal disease)
 Use diuretic-based antihypertensive therapy, ACE inhibitors,
and beta-blockers
 Glycemic control helps to prevent HF in diabetes mellitus
 Treat hyperlipidemia in patients with Hx of MI
 Encourage weight loss, smoking cessation; regular exercise;
healthy diet
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Which presenting features help to
distinguish HFpEF from HFrEF?
 HFpEF
 Hx hypertension & AF slightly more prevalent
 Rapid onset of dyspnea with marked hypertension,
particularly in elderly women
 AF or LV hypertrophy on ECG
 HFrEF
 Cardiac output somewhat lower, CAD more prevalent
 Slower-onset HF with Hx coronary disease, particularly in
middle-aged men
 LBBB or evidence prior ischemic injury
 Both often present with…
 Dyspnea, impaired exercise tolerance, orthopnea,
paroxysmal nocturnal dyspnea
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Which diagnostic tests should the clinician
order for patients with suspected HF?
 Electrocardiography
 Radiography
 Echocardiography
 Laboratory tests
 Plasma BNP or NT-proBNP
 CBC: ? anemia, serum electrolytes, creatinine, glucose,
liver function, urinalysis
 Renal function and electrolytes
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What additional tests should clinicians
consider for patients with suspected HFpEF?
 Cardiac catheterization (for new-onset HF)
 Left heart: measure LVEDP + coronary arteriography
 Right heart: if needed to evaluate valvular heart disease
suggested by echo, or if pulmonary hypertension not
explained by left heart disease
 When abnormal myocardial function present
(? Infiltrative processes, constriction, others), consider:
 Myocardial or fat pad tissue CT or MRI
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What are the criteria for establishing the
diagnosis?
 History and physical examination
 Radiography
 BNP levels
 Echocardiography
Requirements for Diagnosis
• Presence of signs and/or symptoms of HF
• Preserved systolic LV function (EF ≥45%–50%)
• Evidence of diastolic LV dysfunction, elevated LV filling
pressures, or surrogate markers of diastolic LV dysfunction
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What is the role of BNP in diagnosis and
management?
 Levels usually lower in HFpEF than HFrEF
 When elevated: strong independent predictors of
clinical events in HFpEF
 No consensus on use to guide medical therapy
 NT-proBNP
 Superior for evaluating suspected acute HFpEF
 Sensitive & specific for Dx acute HF in emergency dept:
>450 pg/mL (<50y); >900 pg/mL (≥50y)
 BNP
 Falsely negative in up to 20% with HFpEF
 Doesn’t correlate with symptoms
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
CLINICAL BOTTOM LINE: Diagnosis…
 Signs and symptoms
 Impaired exercise tolerance, orthopnea, dyspnea, and signs
suggestive of HF
 History may include hypertension and atrial fibrillation
 Diagnosed based on H&P exam, x-rays, BNP levels, & ECHO
 Criteria for diagnosing HFpEF
 Signs / sxs of HF
 Preserved systolic LV function (EF ≥45%–50%)
 Evidence of: diastolic LV dysfunction, elevated LV filling
pressures or surrogate markers of diastolic LV dysfunction
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
How should HFpEF be treated?
 Reduce preload
 Use diuretics and vasodilators
 BUT NOTE: Assess Volume Status carefully as aggressive
reduction may cause hypotension if hypertensive &
normovolemic
 Consider control of hypertension with vasodilators alone
 Treat acute HFpEF
 First-line therapy: Vasodilators
 I.V. nitrates + furosemide (improve cardiac output and
reduce the symptoms)
 Nitroglycerin to relieve acute pulmonary edema
 Avoid aggressive diuresis (may cause hypotension)
 Heart rate control, with particular attention in rapid AF
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
 Provide long-term treatment of hypertension
 Improves diastolic tissue velocity in hypertension w/o HF
 If no comorbid conditions: thiazide diuretics
 If coronary atherosclerosis or AF: beta-blocker
 Reduce / reverse adverse remodeling: ARBs
 Manage Atrial Fibrillation
 In HFpEF + AF: restore normal HR and NSR to improve
symptoms (maybe not outcomes)
 Rate control first: AV nodal blocking agents + β-blockers
 Rhythm control: when rate control not achieved or when
symptoms persist despite rate control
 Immediate electrical cardioversion: new-onset AF and
myocardial ischemia, symptomatic hypotension, or
pulmonary congestion or rapid ventricular response
uncontrolled by appropriate pharmacologic measures
 Anticoagulation: to reduce thromboembolism risk
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
When should inotropic agents be
considered?
 Not indicated
 Increase inotropy and heart rate
 Have no lusitropic effects
 Studies on digoxin showed no significantly positive result
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
How does drug therapy for HFpEF differ
from that of HFrEF?
 Many of the same drugs are used… but evidence differs
 HFrEF: Improved mortality and morbidity with ACE
inhibitors, ARBs, β-blockers, and aldosterone antagonists
 HFpEF: No similar improvements found from the therapies
 HFpEF focus: symptom relief, BP and heart rate control
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
Are any novel drug therapies being
investigated for HFpEF?
 Spirinolactone
 Proven therapy for HFrEF
 Under investigation for HFpEF (TOPCAT study)
 Sildenafil (phosophodiesterase-5 inhibition)
 In small study: Reduced pulmonary arterial pressure,
improved right ventricular systolic function, reduced right
atrial pressure, improved QOL
 Efficacy being studied in larger RELAX trial
Requires further / completion of studies
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What are potential triggers of
decompensation?
 Dietary indiscretion
 Use of NSAIDs
 Medication nonadherence
 Dysrhythmias (particularly AF)
 Ischemia or infarction
 Hypertension
 Worsening renal function
 Valvular cardiac disease
 Alcohol abuse
 Infection
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What is the role of diet and monitoring weight?
 Advise patients to weigh themselves daily
 Unexpected weight gain may warrant prompt action
 If weight gain, increased edema, other HF symptoms
occur, patient should promptly call health care provider
 Sodium restriction recommended in symptomatic HF
 To prevent fluid retention
 Fluid restriction (≤1.5-2 L/day)
 For severe symptoms of HF, especially hyponatremia
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What should clinicians advise patients with
HFpEF about exercise?
 Advise regular, moderate daily activity
 Aerobic exercise especially beneficial
 Improve CV performance
 Lowers blood pressure
 Prevents or reverses deconditioning
 Increases energy levels
 Reduces symptoms of HF
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
How should clinicians assess the response
to therapy for HFpEF?
 ? Symptom alleviation
 ? Functional capacity improvement
 ? Hospitalizations for decompensated HFpEF decreased
 Other treatment targets…
 Optimal blood pressure control
 Adequate heart rate control in AF
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
What is the prognosis of HFpEF?
 Annual death rate ≈5%
 ≈50% die of noncardiovascular diseases
 Risk factors for mortality in HFpEF
 Increasing age, male gender
 Higher natriuretic peptide levels, higher NYHA class
 Coronary artery or peripheral vascular disease
 Diabetes mellitus, chronic renal insufficiency
 Lower EF, restrictive filling pattern on Doppler ECHO
 Low and very high BMI (in HFpEF)
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
How should patients with HFpEF be followed?
 Educate patients on signs of fluid retention
 Provide guidelines for using a flexible diuretic regimen
 Provide telephone access to health care providers
 Emphasize low-salt diet + medical regimen compliance
 Frequency of follow-up visits depends stability of patient
 See w/in 7d of hospital discharge for decompensated HF
 See well-compensated patient every 4 to 6 months
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
When should patients with HFpEF be
hospitalized?
 Respiratory failure secondary to pulmonary edema
 Moderate to severe volume overload
 Atrial fibrillation with rapid ventricular response
 Severe hypotension or hypertension
 Need for close monitoring during therapy (e.g., of renal
function, electrolytes)
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
When should clinicians consider
consulting a cardiologist?
 Diagnosis of HFpEF uncertain
 Cause of HFpEF unclear
 Patient symptomatic despite treatment
 Frequent hospitalizations for decompensation
 Comorbid cardiac conditions complicate management
(CAD or dysrhythmia)
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.
CLINICAL BOTTOM LINE: Treatment…
 Treating the triggers of HF decompensation
 Relieve acute pulmonary congestion and intravascular and
interstitial volume excess
 Alleviate symptoms, improve functional capacity, and
decrease hospitalizations
 Aim for optimal BP & adequate heart rate control in AF
 Educate patients to recognize the signs of fluid retention
 Use flexible diuretic regimen if needed
 Emphasize low-salt diet + medical regimen compliance
 Consult cardiologist when…
 Diagnosis uncertain or cause unclear
 Patient symptomatic despite treatment
© Copyright Annals of Internal Medicine, 2012
Ann Int Med. 157 (3): ITC2-1.