Internal Medicine · Year 3 · from Internal Medicine

Case 2: Heart Failure with Preserved Ejection Fraction (HFpEF)

Patient Presentation

A 72-year-old woman with hypertension, type 2 diabetes, and atrial fibrillation presents with gradually worsening exertional dyspnea over 6 months. She becomes short of breath climbing one flight of stairs and has difficulty doing housework. She has gained 8 pounds and notes swollen ankles. She denies chest pain or palpitations.

Vital Signs

  • Blood Pressure: 158/92 mmHg
  • Heart Rate: 82 bpm (irregularly irregular)
  • Respiratory Rate: 18/min
  • Oxygen Saturation: 96% on room air
  • BMI: 34 kg/m²

Physical Examination

  • General: Obese, mild dyspnea with talking
  • HEENT: JVD to mid-neck at 45°
  • Cardiovascular: Irregularly irregular rhythm, S4 gallop, no murmurs
  • Pulmonary: Bibasilar crackles
  • Extremities: 2+ pitting edema to knees bilaterally

Laboratory and Imaging

  • BNP: 380 pg/mL
  • Creatinine: 1.2 mg/dL
  • HbA1c: 7.8%
  • Echocardiogram:
  • EF 62%
  • Concentric LVH
  • Grade II diastolic dysfunction (E/e' ratio 15)
  • Left atrial enlargement
  • Moderate tricuspid regurgitation

Clinical Image

Figure 2: Doppler echocardiography demonstrating elevated E/e' ratio consistent with elevated left ventricular filling pressures and diastolic dysfunction.

Image Source: Educational illustration for teaching purposes.

Questions

  1. What criteria support the diagnosis of HFpEF in this patient?
  • A) Preserved EF alone
  • B) Signs/symptoms of HF, preserved EF (≥50%), elevated BNP, structural heart disease, diastolic dysfunction
  • C) Elevated BNP only
  • D) Atrial fibrillation with dyspnea
  1. What is the H2FPEF score used for?
  • A) Determining prognosis in HFpEF
  • B) Calculating probability of HFpEF diagnosis
  • C) Guiding medication selection
  • D) Staging heart failure severity
  1. Which medication class has proven mortality benefit in HFpEF?
  • A) ACE inhibitors
  • B) Beta-blockers
  • C) SGLT2 inhibitors
  • D) Digoxin
  1. What are the key differences between HFrEF and HFpEF management?
  1. What comorbidities commonly contribute to HFpEF and should be addressed?

Answers

  1. B) Signs/symptoms of HF, preserved EF (≥50%), elevated BNP, structural heart disease, diastolic dysfunction - Diagnosis requires symptoms/signs of HF plus preserved EF (≥50%) plus objective evidence of cardiac structural and/or functional abnormalities or elevated natriuretic peptides.
  1. B) Calculating probability of HFpEF diagnosis - The H2FPEF score uses clinical and echocardiographic variables (Heavy/BMI >30, Hypertensive, atrial Fibrillation, Pulmonary HTN, Elder >60, Filling pressures) to estimate probability of HFpEF.
  1. C) SGLT2 inhibitors - The EMPEROR-Preserved and DELIVER trials demonstrated that SGLT2 inhibitors reduce heart failure hospitalizations and cardiovascular death in HFpEF. This is the only class with robust mortality/morbidity benefit in HFpEF.
  1. Key differences in HFrEF vs HFpEF management:
  • HFrEF: All four GDMT pillars (BB, ARNI/ACEi/ARB, MRA, SGLT2i) have mortality benefit
  • HFpEF: Only SGLT2 inhibitors have proven benefit; diuretics for congestion
  • Both: Treat underlying conditions, sodium/fluid restriction, cardiac rehab
  • HFpEF: Focus on comorbidity management (HTN, AF, obesity, diabetes)
  • Rate control is important if AF present in both
  1. Comorbidities contributing to HFpEF:
  • Hypertension (causes LVH and diastolic dysfunction)
  • Obesity (increases cardiac workload, inflammation)
  • Diabetes mellitus
  • Atrial fibrillation
  • Coronary artery disease
  • Chronic kidney disease
  • Sleep apnea (obstructive)
  • Pulmonary hypertension Aggressive management of these conditions is central to HFpEF treatment.

All cases for this lecture as Markdown