Heart Failure with Preserved Ejection Fraction - A Review

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Abstract

Heart failure with preserved left ventricular ejection fraction (HF-PEF), sometimes named diastolic heart failure, is a common condition most frequently seen in the elderly and is associated with arterial hypertension and left ventricular (LV) hypertrophy. Symptoms are attributed to a stiff left ventricle with compensatory elevation of filling pressure and reduced ability to increase stroke volume by the Frank-Starling mechanism. LV interaction with stiff arteries aggravates these problems. Prognosis is almost as severe as for heart failure with reduced ejection fraction (HF-REF), in part reflecting co-morbidities. Before the diagnosis of HF-PEF is made, non-cardiac etiologies must be excluded. Due to the non-specific nature of heart failure symptoms, it is essential to search for objective evidence of diastolic dysfunction which, in the absence of invasive data, is done by echocardiography and demonstration of signs of elevated LV filling pressure, impaired LV relaxation, or increased LV diastolic stiffness. Antihypertensive treatment can effectively prevent HF-PEF. Treatment of HF-PEF is symptomatic, with similar drugs as in HF-REF.

Citation
US Cardiology 2012;9(2):90-5
DOI
https://doi.org/10.15420/usc.2012.9.2.90

Abstract

Heart failure with preserved left ventricular ejection fraction (HF-PEF), sometimes named diastolic heart failure, is a common condition most frequently seen in the elderly and is associated with arterial hypertension and left ventricular (LV) hypertrophy. Symptoms are attributed to a stiff left ventricle with compensatory elevation of filling pressure and reduced ability to increase stroke volume by the Frank-Starling mechanism. LV interaction with stiff arteries aggravates these problems. Prognosis is almost as severe as for heart failure with reduced ejection fraction (HF-REF), in part reflecting co-morbidities. Before the diagnosis of HF-PEF is made, non-cardiac etiologies must be excluded. Due to the non-specific nature of heart failure symptoms, it is essential to search for objective evidence of diastolic dysfunction which, in the absence of invasive data, is done by echocardiography and demonstration of signs of elevated LV filling pressure, impaired LV relaxation, or increased LV diastolic stiffness. Antihypertensive treatment can effectively prevent HF-PEF. Treatment of HF-PEF is symptomatic, with similar drugs as in HF-REF.

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References
  1. Bursi F, Weston SA, Redfield MM, et al., Systolic and diastolic heart failure in the community, JAMA 2006;296:2209–16.
    Crossref | PubMed
  2. Vasan RS, Larson MG, Benjamin EJ, et al., Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort, J Am Coll Cardiol, 1999;33:1948–55.
    Crossref | PubMed
  3. Senni M, Tribouilloy CM, Rodeheffer RJ, et al., Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991, Circulation, 1998;98:2282–9.
    Crossref | PubMed
  4. Yancy CW, Lopatin M, Stevenson LW, et al., Clinical presentation, management, and in-hospital outcomes of patients admitted with acute decompensated heart failure with preserved systolic function: a report from the Acute Decompensated Heart Failure National Registry (ADHERE) Database, J Am Coll Cardiol, 2006;47:76–84.
    Crossref | PubMed
  5. Owan TE, Hodge DO, Herges RM, et al., Trends in prevalence and outcome of heart failure with preserved ejection fraction, N Engl J Med, 2006;355:251–9.
    Crossref | PubMed
  6. Oh JK, Hatle L, Tajik AJ, Little WC, Diastolic heart failure can be diagnosed by comprehensive two-dimensional and Doppler echocardiography, J Am Coll Cardiol, 2006;47:500–6.
    Crossref | PubMed
  7. Paulus WJ, Tschope C, Sanderson JE, et al., How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology, Eur Heart J, 2007;28:2539–50.
    Crossref | PubMed
  8. Maurer MS, Spevack D, Burkhoff D, Kronzon I, Diastolic dysfunction: can it be diagnosed by Doppler echocardiography?, J Am Coll Cardiol, 2004;44:1543–9.
    Crossref | PubMed
  9. Yu CM, Lin H, Yang H, et al., Progression of systolic abnormalities in patients with "isolated" diastolic heart failure and diastolic dysfunction, Circulation, 2002;105:1195–201.
    Crossref | PubMed
  10. Yusuf S, Pfeffer MA, Swedberg K, et al., Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARMPreserved Trial, Lancet, 2003;362:777–81.
    Crossref | PubMed
  11. Massie BM, Carson PE, McMurray JJ, et al., Irbesartan in patients with heart failure and preserved ejection fraction, N Engl J Med, 2008;359:2456–67.
    Crossref | PubMed
  12. Smith GL, Masoudi FA, Vaccarino V, et al., Outcomes in heart failure patients with preserved ejection fraction: mortality, readmission, and functional decline, J Am Coll Cardiol, 2003;41:1510–8.
    Crossref | PubMed
  13. Caruana L, Petrie MC, Davie AP, McMurray JJ, Do patients with suspected heart failure and preserved left ventricular systolic function suffer from "diastolic heart failure" or from misdiagnosis? A prospective descriptive study, BMJ, 2000;321:215–8.
    Crossref | PubMed
  14. Tan YT, Wenzelburger F, Lee E, et al., The pathophysiology of heart failure with normal ejection fraction: exercise echocardiography reveals complex abnormalities of both systolic and diastolic ventricular function involving torsion, untwist, and longitudinal motion, J Am Coll Cardiol, 2009;54:36–46.
    Crossref | PubMed
  15. Baicu CF, Zile MR, Aurigemma GP, Gaasch WH, Left ventricular systolic performance, function, and contractility in patients with diastolic heart failure, Circulation, 2005;111:2306–12.
    Crossref | PubMed
  16. Gheorghiade M, Abraham WT, Albert NM, et al., Systolic blood pressure at admission, clinical characteristics, and outcomes in patients hospitalized with acute heart failure, JAMA, 2006;296:2217–26.
    Crossref | PubMed
  17. Weber KT, Brilla CG, Pathological hypertrophy and cardiac interstitium. Fibrosis and renin-angiotensin-aldosterone system, Circulation, 1991;83:1849–65.
    Crossref | PubMed
  18. Kawaguchi M, Hay I, Fetics B, Kass DA, Combined ventricular systolic and arterial stiffening in patients with heart failure and preserved ejection fraction: implications for systolic and diastolic reserve limitations, Circulation, 2003;107:714–20.
    Crossref | PubMed
  19. Kitzman DW, Higginbotham MB, Cobb FR, et al., Exercise intolerance in patients with heart failure and preserved left ventricular systolic function: failure of the Frank-Starling mechanism, J Am Coll Cardiol, 1991;17:1065–72.
    Crossref | PubMed
  20. Gandhi SK, Powers JC, Nomeir AM, et al., The pathogenesis of acute pulmonary edema associated with hypertension, N Engl J Med, 2001;344:17–22.
    Crossref | PubMed
  21. Borlaug BA, Melenovsky V, Russell SD, et al., Impaired chronotropic and vasodilator reserves limit exercise capacity in patients with heart failure and a preserved ejection fraction, Circulation, 2006;114:2138–47.
    Crossref | PubMed
  22. Brubaker PH, Joo KC, Stewart KP, et al., Chronotropic incompetence and its contribution to exercise intolerance in older heart failure patients, J Cardiopulm Rehabil, 2006;26:86–9.
    Crossref | PubMed
  23. Chen CH, Nakayama M, Nevo E, et al., Coupled systolicventricular and vascular stiffening with age: implications for pressure regulation and cardiac reserve in the elderly, J Am Coll Cardiol, 1998;32:1221–7.
    Crossref | PubMed
  24. Wandt B, Bojo L, Hatle L, Wranne B, Left ventricular contraction pattern changes with age in normal adults, J Am Soc Echocardiogr, 1998;11:857–63.
    Crossref | PubMed
  25. Smiseth OA, Refsum H, Tyberg JV, Pericardial pressure assessed by right atrial pressure: a basis for calculation of left ventricular transmural pressure, Am Heart J, 1984;108:603–5.
    Crossref | PubMed
  26. Tyberg JV, Taichman GC, Smith ER, et al., The relationship between pericardial pressure and right atrial pressure: an intraoperative study, Circulation, 1986;73:428–32.
    Crossref | PubMed
  27. Appleton CP, Hatle LK, Popp RL, Relation of transmitral flow velocity patterns to left ventricular diastolic function: new insights from a combined hemodynamic and Doppler echocardiographic study, J Am Coll Cardiol, 1988;12:426–40.
    Crossref | PubMed
  28. Oh JK, Appleton CP, Hatle LK, et al., The noninvasive assessment of left ventricular diastolic function with two-dimensional and Doppler echocardiography, J Am Soc Echocardiogr, 1997;10:246–70.
    Crossref | PubMed
  29. Opdahl A, Remme EW, Helle-Valle T, et al., Determinants of left ventricular early-diastolic lengthening velocity: independent contributions from left ventricular relaxation, restoring forces, and lengthening load, Circulation, 2009;119:2578–86.
    Crossref | PubMed
  30. Nagueh SF, Appleton CP, Gillebert TC, et al., Recommendations for the evaluation of left ventricular diastolic function by echocardiography, J Am Soc Echocardiogr, 2009;22:107–33.
    Crossref
  31. Rossvoll O, Hatle LK, Pulmonary venous flow velocities recorded by transthoracic Doppler ultrasound: relation to left ventricular diastolic pressures, J Am Coll Cardiol, 1993;21:1687–96.
    Crossref | PubMed
  32. Chattopadhyay S, Alamgir MF, Nikitin NP, et al., Lack of diastolic reserve in patients with heart failure and normal ejection fraction, Circ Heart Fail, 2010;3:35–43.
    Crossref | PubMed
  33. Burgess MI, Jenkins C, Sharman JE, Marwick TH, Diastolic stress echocardiography: hemodynamic validation and clinical significance of estimation of ventricular filling pressure with exercise, J Am Coll Cardiol, 2006;47:1891–900.
    Crossref | PubMed
  34. Chan AK, Govindarajan G, Del Rosario ML, et al., Dobutamine stress echocardiography Doppler estimation of cardiac diastolic function: a simultaneous catheterization correlation study, Echocardiography, 2011;28:442–7.
    Crossref | PubMed
  35. Maisel AS, Krishnaswamy P, Nowak RM, et al., Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure, N Engl J Med, 2002;347:161–7.
    Crossref | PubMed
  36. Atisha D, Bhalla MA, Morrison LK, et al., A prospective study in search of an optimal B-natriuretic peptide level to screen patients for cardiac dysfunction, Am Heart J, 2004;148:518–23.
    Crossref | PubMed
  37. Zaphiriou A, Robb S, Murray-Thomas T, et al., The diagnostic accuracy of plasma BNP and NTproBNP in patients referred from primary care with suspected heart failure: results of the UK natriuretic peptide study, Eur J Heart Fail, 2005;7:537–41.
    Crossref | PubMed
  38. Bhatia RS, Tu JV, Lee DS, et al., Outcome of heart failure with preserved ejection fraction in a population-based study, N Engl J Med, 2006;355:260–9.
    Crossref | PubMed
  39. Moser M, Hebert PR, Prevention of disease progression, left ventricular hypertrophy and congestive heart failure in hypertension treatment trials, J Am Coll Cardiol, 1996;27:1214–8.
    Crossref | PubMed
  40. Kostis JB, Davis BR, Cutler J, et al., Prevention of heart failure by antihypertensive drug treatment in older persons with isolated systolic hypertension. SHEP Cooperative Research Group, JAMA, 1997;278:212–6.
    Crossref | PubMed