HEART FAILURE WITH PRESERVED EJECTION FRACTION

1. Clinical Features and Diagnosis of HFpEF
Presented by- Maj Deepak Garg
Moderator- Lt Col Nitin Bajaj

2. References
• ESC-2016
• ACCF/AHA- 2013
• NEJM- Nov 2016
• API update-2017
• Braunwald’s Heart Disease – 10th edition

3. Definition
ESC-2016

4. ESC-2016

5. ACCF/AHA Stages of HF

6. History
• Female
• Elderly
• H/o HTN, Obesity, DM, AF, CKD, CAD, OSA
• H/o exposure to cardiotoxic drugs/ radiation
• Improvement with diuretcs
• Family history

7. Symptoms
Typical
• Breathlessness
• Orthopnea
• PND
• Reduced exercise tolerence
• Fatigue
• Ankle swelling
Atypical
• Nocturnal cough
• Wheezing
• Bloated feeling
• Loss of appetite
• Confusion, depression
• Palpitation
• Dizziness, syncope
• Bendopnea
ESC-2016

8. Signs
More specific Less specific
• Tachycardia, Tachypnoea
• Narrow pulse pressure
• Peripheral oedema
• Crepitations
• Hepatomegaly, Ascities
• Elevated JVP
• Abdominojugular reflux
• S3
• Laterally displaced apical
impulse
ESC-2016

9. ECG
• Low Sp (66%), High Sn (89%)
• Etiology (AF, IHD)
• Indication of therapy (Anticoagulation, Pacing,
CRT)
ESC-2016

10. Chest X-ray
• New onset HF or Acute decompensated HF
• To assess Heart size and Pulmonary
congestion
• To exclude/ confirm alternative diagnosis

11. Natriuretic Peptides (NPs)
• Non-acute setting
– BNP >35 pg/ml
– NT-pro BNP >125 pg/ml
• Acute setting
– BNP >100 pg/ml
– NT-pro BNP >300 pg/ml
• NPV- 94-98%
• Useful to achieve optimal dosing of GDMT
ESC-2016

12. Causes of Elevated NP
ESC-2016

13. Cardiac Troponin T or I
• Elevated even without myocardial ischemia
• Impaired hemodynamics
• Progressive LV dysfunction
• Increased mortality

14. Biomarkers in HF
• ST 2
• Galectin 3
• Copeptin (CT-proAVP)
• Adrenomedullin
ACCF/AHA- 2013

15. TTE
• Myocardial structural and functional
assessment (I,C)
• Guidance for (I,C)
– pharmacological and device treatment
– Valve correction

16. TTE
Structural assessment
• Left atrial volume index (LAVI) >34 mL/m2
• LV volume <75 ml/m2
• Left ventricular mass index
> 115 g/m2 (Male)
> 95 g/m2 (Female)
ESC-2016

17. TTE
Structural assessment
• Ratio of LV Mass to Volume (M/V)
• Relative wall thickness (RWT)- Ratio of LV wall
thickness to LV internal diameter (LVID)
Braunwald’s Heart Disease – 10th edition

18. Relative Wall Thickness
LV Mass Index

19. TTE
Functional assessment
Criteria for Diastolic dysfunction :
• E/e’ >13
• Mean e’ <9 cm/s (septal and lateral wall)
E- early diastolic mitral flow velocity
e‘ – mitral annular velocity
ESC-2016

21. Stress ECHO
• To assess inducible ischemia and/or
myocardial viability
• To assess exercise induced diastolic
dysfunction

22. TEE
• Not needed routinely
• Valve disease, CHD
• To r/o intracavitary thrombi in AF

23. CMR
• Gold std - Rt and Lt ventricle volume, mass and EF
(I,C)
• Investigation of choice - complex congenital heart
disease (I,C)
• Myocardial infiltrative (amyloidosis) /
inflammatory (sarcoidosis) disorders (I,C)
• Myocardial fibrosis (II,C)
ESC-2016

24. Cardiac CT
• To visualize the coronary anatomy in patient
with low pre-test probability of CAD or
equivocal non-invasive test (II,C)
ESC-2016

25. Rt Heart Catheterization
• Routine use is not recommended in normo-
tensive patient improving with therapy (III,B)
• MCS or transplantation (I,C)
• Clinically indeterminate volume status (II,C)
• Refractory to initial therapy (II,C)
ESC-2016

26. CAG
• HF with (I,C)
– Angina recalcitrant to medical therapy
– Symptomatic ventricular arrhythmia
– Aborted cardiac arrest
• HF with (II,C)
– High pre-test probability of CAD
– Presence of ischemia in non-invasive stress test
ACCF/AHA- 2013

27. Endomyocardial biopsy
• Not routinely recommended
• Suspected acute rejection after heart
transplantation
• Myocardial infiltrative disease
• Determine chemotherapy for primary cardiac
amyloidosis
• Rapidly progressive unexplained cardiomyopathy
• Active myocarditis (Giant cell myocarditis)
ACCF/AHA- 2013

28. Genetic Testing
• HCM- (MYH7, MYBPC3)
• ARVC (desmosomal gene mutation)
• Restrictive cardiomyopathy

29. Thank you