What is HFpEF & How do we make the diagnosis? Barry Borlaug MD, - - PowerPoint PPT Presentation

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What is HFpEF & How do we make the diagnosis? Barry Borlaug MD, - - PowerPoint PPT Presentation

Jul 12, 2023 132 likes •292 views

What is HFpEF & How do we make the diagnosis? Barry Borlaug MD, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA Introduction Review of Heart Failure with Preserved Ejection Fraction: Definition of HFpEF

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What is HFpEF &

How do we make the diagnosis?

Barry Borlaug MD, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA

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Review of Heart Failure with Preserved Ejection Fraction:

  • Definition of HFpEF
  • Diagnostic approaches HFpEF

Introduction

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What is HFpEF?

  • Inability of the heart to pump blood adequately at normal filling pressures in

pt w EF≥50%

  • Clinical diagnosis relies on finding objective evidence:
  • High filling pressures
  • JVD, S3, rales, Kerley B lines, etc
  • ↑NT proBNP, E/e’, LAVI, PASP
  • Cath
  • Inadequate output
  • CPXT
  • Cath
  • Exclude other etiologies that we treat differently

How do we make the diagnosis?

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LAE, LVH, E/e’>13 + e’<9

Ponikowski Eur Heart J 2016

Mayo Data: Sensitivity 60%!!

Obokata…Borlaug Circulation 2017

How to Diagnose HFpEF: 2016 ESC Guidelines

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  • EF = 60%, h/o HTN, metabolic syndrome
  • NYHA II-III dyspnea and fatigue
  • No clear episodes of volume overload
  • Appears “Euvolemic”, normal BNP
  • Echo:

– Mild LAE – E/A 1.1, E/e’ 11, RVSP 32

ESC algorithm says “no HFpEF”

70 yo woman with DOE

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20 40 60 80 100 120 140 160 180

PCWP=LVEDP=12 mmHg; CO 5.7 l/min PCWP=LVEDP=40 mmHg; CO 7.8 l/min 40 Watts Exercise

Referred for invasive hemodynamic assessment

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Dx: HFpEF

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58% of pts with normal exam, echo, BNP & resting hemos have HF by exercise

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<125

% of HFpEF patients

10 20 30 40 50

<200 <300 NT-proBNP cutoff used (pg/ml)

Obokata, Borlaug Circulation 2017

Normal NT-proBNP does NOT exclude HFpEF

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NCD HFpEF 10 20 30 40 50

p<0.0001 E/e’ medial NCD HFpEF

5 10 15 20 25 30 35 10 20 30 40 50 60

PCWP (mm Hg)

r= 0.63 p<0.0001 E/e’ medial PCWP (mm Hg)

Obokata, Borlaug Circulation 2017

E/e’ ratio: Useful when High Only

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NCD HFpEF 10 20 30 40

p<0.0001

Peak VO2 (ml/min/kg)

Reddy, Borlaug JACC Heart Fail 2018

Cardiopulmonary Exercise Testing Does Not Provide Robust Discrimination of Causes

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Reddy, Borlaug Circulation 2018

A simplified, Bayesian Approach to Dx: The H2FPEF Score

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Valvular heart disease Coronary artery disease Pulmonary arterial hypertension High output heart failure Constrictive pericarditis Infiltrative or restrictive cardiomyopathy Hypertrophic cardiomyopathy Right ventricular myopathies Pulmonary embolism

Cardiac Causes of Dyspnea that may Mimic HFpEF

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Summary

HFpEF is defined by symptoms (i.e. dyspnea) due to failure of the heart to pump blood adequately to the body at normal filling pressures. The diagnosis of HFpEF is made by demonstrating objective evidence of high filling pressures and/or inadequate cardiac output. This is sometimes achieved by physical exam, echocardiography, natriuretic peptide testing and cardiopulmonary exercise testing, but each of these has limitations in sensitivity. Invasive diastolic stress testing represents the gold standard test to identify or rule out HFpEF. The H2FPEF score can be used to estimate the probability that HFpEF is present in patients with unexplained dyspnea and may inform further workup. Remember to exclude disorders that may mimic HFpEF but are treated differently.