The panel presented three challenging cases of heart failure with preserved ejection fraction (HFPEF) (see Update on Diastolic Heart Failure). In an innovative twist, the panel solicited feedback from a standing-room-only audience through SmartPhone technology—attendees voted for their favored diagnostic approach, therapy, or final diagnosis, with voting results instantly integrated into the presenter’s Powerpoint display. Key take-home messages included:
1. Patients with HFPEF can present with chest pain unrelated to a coronary syndrome: Elderly patients with diastolic dysfunction can experience severe chest pain, edema, and borderline enzyme results, but little evidence exists to support aggressive catheterization and revascularization in this cohort. Despite this, panelists felt compelled to support cardiac catheterization in an HFPEF patient presenting with acute angina and edema, and agreed with the presenting team’s decision to stent a single-vessel lesion that might have accounted for the findings.
2. If you don’t think of renal artery stenosis (RAS), you won’t make the diagnosis: HFPEF patients usually have hypertension; if hypertension and fluid retention become refractory to treatment, evaluate the renal arteries and consider revascularization if critical stenosis is discovered. The patient described in the first bullet point did not improve until his RAS was treated (single-vessel coronary disease was probably "true, true, and unrelated").
3. Echocardiogram and functional MRI studies have a prominent role in sorting out chest pain in the setting of HFPEF: absence of wall motion abnormalities points away from acute coronary syndromes as the explanation for chest pain.
4. No definitive treatment exists for HFPEF; the best approach is aggressive management of hypertension and diabetes. Aggressive use of beta-blockade has fallen out of favor because of concerns about chronotropic incompetence. The panelists agreed that cardiac rehabilitation and exercise are very helpful, exerting positive effects by improving oxygen extraction in skeletal muscle and addressing the problems observed in HFPEF during exercise. Every HFPEF patient should have an exercise program. Some evidence exists for the use of oral nitrates, either before exercise or chronically, to decrease filling pressure that can cause fluid backup.
5. Left ventricular hypertrophy is not a pre-requisite for HFPEF: Hemodynamic effects of the "stiff ventricle" pre-date overt LVH in many of these patients. Make the diagnosis on the basis of clinical pump failure in the setting of preserved systolic ejection fraction.
6. HFPEF can also be caused by constrictive pericardial disease: If a younger patient presents with signs of diastolic heart failure, especially without long-standing hypertension, consider a pericardial syndrome. Echocardiogram and functional MRI will be mainstays of the diagnosis.
Case-based Learning Session: Heart Failure with Preserved Ejection Fraction (HFPEF), a panel discussion at ACC.11, April 3, 2011. New Orleans, La.
Chair: William Little, MD (Wake Forest University)
Discussants: Dalane Kitzman, MD (Wake Forest), Barry Borlaug, MD (Mayo Clinic), Allen Klein, MD (Cleveland Clinic), Matthew Maurer, MD (Columbia), Scott Solomon, MD (Harvard)
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