B P6 C51 Heart Failure with Preserved and Mildly Reduced Ejection Fraction Flashcards
(92 cards)
In the Framingham Heart Study (FHS), an examination of predictors of 8-year risk of HF patients with LVEF >45% versus those with LVEF </=45% showed that predictors of all incident HF included:
Older age
Male sex
Hypertension
Higher body mass index (BMI)
Increasing heart rate
Coronary artery disease (CAD)
Diabetes mellitus
Smoking
Valve disease
Lower HDL cholesterol
Atrial fibrillation
LV hypertrophy or LBBB
Specifically in those with higher LVEF, risk factors included:
Higher BMI
Atrial fibrillation
Smoking
In contrast _____ were associated with higher risk of HFrEF
Male sex
Hypertension
Higher heart rate
Prior cardiovascular disease
Higher cholesterol level
LV hypertrophy
LBBB
However, _____ was associated with a higher risk of HFpEF and HFmrEF whereas _____ were associated with higher risk of HFrEF
HFpEF and HFmrEF: Old age
HFrEF: male sex and prior myocardial infarction
_____ is the most common arrhythmia in patients with HFpEF and HFmrEF, with a prevalence of 20% to 40% at the time of presentation, and occurring in two-thirds of these patients at some point during their course.
Atrial fibrillation
The _____ meta-analysis inclusive of data from clinical trials, reported that patients with HFpEF had lower risk of death from any cause compared with those with HFrEF independent of age, sex, and etiology.31 The death rate was 12.1 (95% CI: 11.7, 12.6) per 100 patient-years in HFpEF and 14.1 (95% CI: 13.8, 14.4) per 100 patient-years in HFrEF, with an adjusted hazard ratio (HR) of 0.68 (95% CI: 0.64, 0.71) for HFpEF versus HFrEF; death rates were lower in randomized trials alone,and the lower risk in HFpEF than HFrEF was more prominent in ambulatory versus hospitalized patients.3
Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC)
Among cardiovascular causes of death, _____accounted for up to 43% of cardiovascular mortality (“25% to 30% of total deaths) in clinical trials that included patients with HF and LVEF >40%, with HF deaths accounting for another 20% to 30% of cardiovascular deaths
Sudden death
Although total hospitalization rates were similar across the spectrum of LVEF, noncardiovascular hospitalizations were higher in those with _____, whereas cardiovascular hospitalizations were lower, when compared with HFrEF.
NonCV hospitalization: HFpEF
CV hospitalizations: HFrEF
The diagnosis of HFpEF and HFmrEF relies on:
(1) Clinical diagnosis of HF
(2) Evidence of a preserved or only mildly reduced LVEF (LVEF >40%)
The specific LVEF cutoff for HFpEF has been debated and has been different in different contexts, with recent guidelines suggesting that HFpEF should be defined as LVEF 50% and HFmrEF defined as LVEF between 40% and 49%.
Noncardiac Etiologies That Can Mimic the HFpEF Syndrome
Obesity
Chronic lung disease
Chronic kidney disease with minimal cardiac structural or functional abnormalities
Primary cirrhosis
Extrinsic compression of the LA, LV, or IVC
IVC obstruction
Lymphedema
Anemia
However, the diagnosis can be challenging in patients with dyspnea and exercise intolerance who do not have overt signs of elevated filling pressures and natriuretic peptide levels below typical thresholds used to make the diagnosis of HF, which occurs commonly in some patients (up to 30% to 40%, especially in patients who are obese). In these patients, provocative testing (e.g., exercise) can be useful to make the diagnosis by _____.
(1) Echocardiography (elevated E/e% ratio at peak exercise)
OR
(2) Invasive hemodynamic testing (PCWP 25 mm Hg with passive leg raise or during exercise)
Echocardiographic evidence of LV diastolic dysfunction is chal- lenging and should not be used as the sole criteria for the diagnosis of HFpEF for several reasons:
(1) diastolic function on echocardiography may be uninterpretable, equivocal, or misinterpreted;
(2) many older patients without the HF syndrome have evidence of diastolic dysfunction;
(3) while echocardiography is useful for the diagnosis of impaired relaxation, E/e’ ratio (an estimate of LV filling pressures) is often in the indeterminate range (8 to 15), and echocardiography has not proven useful for the assessment of LV chamber compliance in the clinical setting
Two scoring systems have been developed to assist in the diagnosis of HFpEF in patients with dyspnea in whom the diagnosis is in question: the _____.
H2FPEF score
HFA-PEFF score
The H2FPEF score was systematically derived and validated at a single center (Mayo Clinic, Rochester, MN). HFpEF was diagnosed in patients with PCWP >/=15 mm Hg at rest or >/=25 mm Hg during exercise. The final diagnostic model included the following weighted components: _____
BMI >30 g/m2 (2 points)
2 or more antihypertensive medications (1 point)
Atrial fibrillation (3 points)
Echocardiographic PASP >35 mm Hg (1point)
Age >60 years (1 point)
Echocardiographic E/e’ >9 (1 point)
The HFA-PEFF score was developed by a group of experts convened by the European Society of Cardiology Heart Failure Association. The “PEFF” mnemonic stands for _____
Pre-test assessment
Echocardiography and natriuretic peptide score;Functional testing
Final etiology
Scoring system for HFA-PEFF score
5 points is diagnostic of HFpEF
<2 points excludes HFpEF
Although an elevated NP level can be helpful to diagnose HF in patients with LVEF >40%, other causes of elevated NP levels such as _____ must be considered in the differential diagnosis.
Atrial fibrillation
Pulmonary arterial hypertension
Primary RV failure
Acute pulmonary embolism
Chronic kidney disease
High-sensitivity troponin (hsTnT) is also useful in the evaluation of patients with HFpEF and HFmrEF, and elevation in hsTnT can signify a more “myocardial” phenotype of HFpEF, can alert the clinician to the potential presence of an infiltrative cardiomyopathy such as _____, and may reflect impaired subendocardial perfusion due to coronary microvascular dysfunction, particularly if measured during or immediately after exercise testing
Cardiac amyloidosis
. Although not all patients with HFpEF or HFmrEF have LV hypertrophy, the majority have concentric LV remodeling, defined by a relative wall thickness (2 × posterior wall thickness/LV end-diastolic dimension) >0.42.
Assessment of LV mass index in relation to relative wall thickness can also be helpful because it can be used to categorize LV geometry (normal, concentric remodeling, concentric hypertrophy, or eccentric hypertrophy), which can provide clues to the etiology
____ is also very useful for the diagnosis because it pro- vides insight into chronic LA pressure overload.
Although maximal LA volume index to body surface area ___ is the guideline-based cutoff for LA enlargement, it can be challenging to use because of the high prevalence of obesity in these patients, which results in lower values. For these reasons, it is important to examine the LA in relation to the other chambers of the heart
LA volume
LAVI - 34 mL/m2
An LA that is as large or larger than the LV implies that the LA is not emptying properly to adequately fill the LV, which is common in HFpEF.
Therefore, ___ may be better tools to help diagnose and manage these patients
LA minimal volume or LA reservoir strain
It is important to note that other conditions can result in LV hypertrophy and/or LA enlargement in the setting of a preserved LVEF.
These include ____, underscoring the importance of comprehensive echocardiographic assessment in these patients.
Athlete’s heart, high output states (e.g., cirrhosis), and atrial fibrillation