🫀 Mirza's Cardiology Notes

Heart Failure with Preserved Ejection Fraction (HFpEF)

3 min read

  • Related:
  • Elevated LVEDP or LV filling pressures at rest or with exercise in the context of a preserved ejection fraction (≥ 50%)
  • HFpEF should be thought of as a diagnosis of exclusion. After excluding the presence of depressed EF, assessing for HFpEF “masqueraders” is a critical step in evaluation, as each of the mimics have their own unique treatments that differ from the “garden variety” HFpEF.
  • LV diastolic dysfunction is defined by an impairment in relaxation, an ↑ in viscoelastic chamber stiffness, or some combination of the two → symptomatic HF d/t ↑ filling pressures (at rest or with exertion).
    • Elevated filling pressures → dyspnea, impaired exercise capacity, ↑ risk for HF hospitalization, and ↓ survival
  • HFpEF is more than just LV diastolic dysfunction: 1
    • subtle LV systolic dysfunction
      • subtle impairments in systolic function at rest become dramatic during exercise in HFpEF → ↓ exercise capacity, impaired early diastolic recoil and LV suction, impaired cardiac output, and ↑ LV filling pressures
    • LA impairment
    • relative pericardial restraint
    • abnormal right ventricular-pulmonary artery coupling
    • pulmonary vascular disease (Pulmonary Hypertension)
      • PH is extremely common in HFpEF, seen in roughly 80% of patients. Predominantly related to LA hypertension in most cases.
      • ![[Heart Failure with Preserved Ejection Fraction HFpEF-1745700840071.webp|496x218]]
    • systemic vascular stiffening
    • coronary and peripheral microvascular dysfunction
      • may contribute to subendocardial ischemia and impairments in LV longitudinal shortening during stress, especially in the setting of myocardial oxygen supply-demand imbalance
    • chronotropic incompetence
    • ![[Heart Failure with Preserved Ejection Fraction HFpEF-1745700533040.webp]]

HFpEF Phenotypes

  • Rather than having an isolated abnormality in left ventricular (LV) diastolic function, patients with HFpEF display multifaceted limitations in cardiac, vascular, and peripheral functions. 1

![[Heart Failure with Preserved Ejection Fraction HFpEF-1745699844214.webp]] Figure source 1

HFpEF Mimickers

Differential DiagnosisEchocardiographic CluesSubsequent Testing Considered
Hypertrophic cardiomyopathyAsymmetric hypertrophy; ↑↑LV wall thickness; LVOT obstruction; SAMCMR, genetic testing
Restrictive cardiomyopathySmall LV cavity; ↑LV wall thickness; sparkling myocardium, apical sparing; severely reduced tissue Doppler; PE; hepatic vein diastolic flow reversal during inspirationCMR, biopsy, and others
Pulmonary arterial hypertension↑RVSP with no sign of elevated LV filling pressure (e.g., E/A ratio <1); isolated right heart dilation; PA dilation; RVOT Doppler midsystolic notchRight heart catheterization; high-resolution CT
Constrictive pericarditisPericardial thickening; septal bounce; annulus paradoxus and annulus reversus; ↑respiratory variation in mitral/tricuspid flow; hepatic vein diastolic flow reversal during expiration; absence of IVC collapseCT, CMR, right heart catheterization
Valvular heart diseaseMorphological valvular abnormalities; color DopplerDetailed echocardiographic assessments for stenosis/regurgitation; TEE
Coronary artery diseaseRegional wall motion abnormality and thinningCoronary angiography
Chronic thromboembolic pulmonary hypertensionIncreased RVSP with no sign of elevated LV filling pressure; isolated right heart dilation; PA dilation; RVOT Doppler midsystolic notchV/Q scan, high-resolution CT; right heart catheterization ± pulmonary angiography
High-output heart failureIncreased Doppler-derived cardiac output; increased 4 cardiac chamber volumesRight heart catheterization

Echo

  • The combination of the E/e′ ratio and right ventricular systolic pressure has recently been shown to add independent value to the diagnostic evaluation of patients suspected of having HFpEF.
  • HFpEF patients with microvascular dysfunction display more abnormal systolic mechanics by strain and tissue Doppler imaging

H2FPEF Score

![[Heart Failure with Preserved Ejection Fraction HFpEF-1745701551974.webp]]

Footnotes

  1. Obokata M, Reddy YNV, Borlaug BA. Diastolic Dysfunction and Heart Failure With Preserved Ejection Fraction: Understanding Mechanisms by Using Noninvasive Methods. JACC Cardiovasc Imaging. 2020 Jan;13(1 Pt 2):245-257. doi: 10.1016/j.jcmg.2018.12.034. Epub 2019 Jun 12. PMID: 31202759; PMCID: PMC6899218. ↩ ↩2 ↩3

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