Cardiology · Heart Failure
The facts most likely to be tested
HFpEF is defined by a left ventricular ejection fraction (LVEF) ≥ 50% in the presence of clinical signs and symptoms of heart failure.
The primary pathophysiology of HFpEF is diastolic dysfunction, characterized by impaired myocardial relaxation and increased ventricular stiffness.
Hypertension is the single most important and common risk factor for the development of HFpEF.
Physical examination often reveals an S4 gallop, which represents an atrial kick into a stiff, non-compliant left ventricle.
Echocardiography is the diagnostic test of choice to confirm the diagnosis by demonstrating diastolic filling abnormalities and normal systolic function.
SGLT2 inhibitors (e.g., empagliflozin, dapagliflozin) are the only class of medications proven to reduce cardiovascular death and heart failure hospitalizations in patients with HFpEF.
Management of HFpEF focuses on blood pressure control, diuretic therapy for volume overload, and management of comorbidities like atrial fibrillation.
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A 74-year-old woman with a history of long-standing hypertension and obesity presents to the clinic with progressive exertional dyspnea and orthopnea. Physical examination reveals bilateral 2+ pitting edema and an S4 heart sound at the apex. Her lungs are clear to auscultation. An echocardiogram shows a left ventricular ejection fraction of 60% with left atrial enlargement and evidence of impaired myocardial relaxation.
What is the most appropriate pharmacologic therapy to reduce the risk of future heart failure hospitalizations in this patient?
SGLT2 inhibitor
The patient presents with classic signs of HFpEF (preserved EF, S4, hypertension). SGLT2 inhibitors are the current guideline-directed medical therapy (GDMT) shown to improve outcomes in HFpEF patients.
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Etiology / Epidemiology
Predominantly affects elderly women with hypertension and obesity.
Clinical Manifestations
Presents with dyspnea on exertion and pulmonary congestion without reduced systolic function.
Diagnosis
Requires Echocardiogram showing LVEF ≥ 50% and evidence of diastolic dysfunction.
Treatment
Manage comorbidities; SGLT2 inhibitors are the cornerstone of therapy.
Prognosis
High risk of recurrent hospitalizations; mortality remains high despite preserved EF.
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Epidemiology & Etiology
HFpEF is the most common form of heart failure in the elderly population. Primary risk factors include chronic hypertension, obesity, diabetes mellitus, and atrial fibrillation. It is characterized by a stiff, non-compliant left ventricle.
Pertinent Anatomy
The left ventricle exhibits concentric hypertrophy or interstitial fibrosis. This structural rigidity impairs ventricular filling during diastole, leading to elevated left ventricular end-diastolic pressure (LVEDP).
Pathophysiology
Diastolic dysfunction results from impaired myocardial relaxation and increased chamber stiffness. This leads to elevated filling pressures transmitted to the pulmonary vasculature, causing pulmonary venous hypertension. Unlike HFrEF, the systolic contractile function remains preserved.
Clinical Manifestations
Patients present with exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Physical exam may reveal S4 gallop (atrial contraction into a stiff ventricle) and peripheral edema. Acute pulmonary edema is a life-threatening emergency requiring immediate diuresis.
Diagnosis
The Echocardiogram is the diagnostic gold standard, confirming LVEF ≥ 50% and diastolic filling abnormalities. Elevated BNP or NT-proBNP levels support the diagnosis in the setting of clinical symptoms. Invasive left heart catheterization is reserved for diagnostic uncertainty.
Treatment
Management focuses on symptom relief and comorbidity control. SGLT2 inhibitors (e.g., empagliflozin) are the only agents proven to reduce cardiovascular death and hospitalizations. Use diuretics for volume overload, but avoid excessive preload reduction which can cause hypotension. Manage atrial fibrillation aggressively to maintain atrial kick.
Prognosis
Patients face high rates of recurrent hospitalizations and significant morbidity. Long-term management requires strict blood pressure control and weight management to prevent further myocardial remodeling.
Differential Diagnosis
HFrEF: LVEF < 40% on echocardiogram
Constrictive Pericarditis: Kussmaul sign and pericardial calcification
Restrictive Cardiomyopathy: amyloidosis or sarcoidosis infiltration
Pulmonary Hypertension: elevated pulmonary artery pressures without LV filling issues
Valvular Heart Disease: murmur consistent with stenosis or regurgitation