Heart failure with preserved EF (HFPEF):-

Background Patients with heart failure with preserved ejection fraction (HFpEF) have the signs and symptoms of heart failure with a normal or near normal ejection fraction (EF ≥ 50%). Approximately 50% of patients with heart failure have HFpEF and the incidence of HFpEF among heart failure patients is increasing. Conditions that predispose to the development of HFpEF include hypertension, aging, obesity, coronary artery disease, atrial fibrillation, and diabetes mellitus. Management of modifiable risk factors may help prevent the development of symptomatic heart failure. HFpEF is associated with significant 5-year mortality, particularly with increasing age. Evaluation Evaluate for predisposing conditions and for the presence of symptoms and signs of heart failure. Perform transthoracic echocardiography (TTE) to assess left ventricular ejection fraction and left atrial size, to identify other structural abnormalities such as valvular or pericardial disease, and to evaluate parameters of diastolic function (Strong recommendation). Consider magnetic resonance imaging when echocardiography is inadequate (Weak recommendation). Obtain initial blood testing including a complete blood count, serum chemistries, fasting lipid profile, liver function tests, and thyroid-stimulating hormone to identify potential reversible contributing causes of heart failure (Strong recommendation). Obtain B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels (Strong recommendation) but interpret with caution as follows: In patients with ongoing dyspnea at rest, normal or low levels may exclude acute but not chronic heart failure because patients with chronic heart failure may have normal or falsely low BNP or NT-proBNP levels (for example, in patients with obesity). Higher levels are associated with a positive diagnosis of heart failure but may also be due to noncardiac causes and other cardiac causes. Heart failure patients who are successfully treated may present with a lower-than-expected BNP or NT-proBNP compared to levels at the onset of treatment. Consider right heart catheterization in patients where diagnostic uncertainty for HFpEF remains based on noninvasive imaging results and to confirm suspected pulmonary hypertension on echocardiography and its reversibility. Consider the use of a wireless implantable hemodynamic monitoring device in conjunction with a heart failure specialist in selected patients with HFpEF who remain symptomatic despite standard medical therapy to reduce heart-failure-related hospitalization. Management Encourage lifestyle modifications including a healthy diet low in sodium and regular exercise Consider supervised exercise training to improve the patient's quality of life and exercise capacity based on availability and cost. Use diuretics as the first-line agents to relieve symptoms of volume overload (Strong recommendation). Optimize the control of hypertension (Strong recommendation). In patients with HFpEF, who are hypertensive despite the use of a thiazide diuretic, consider angiotensin-converting enzyme (ACE) inhibitors or beta blockers as additional agents for the treatment of hypertension (Weak recommendation). Consider aldosterone receptor antagonists to decrease hospitalizations in selected patients with ejection fraction ≥ 45%, elevated brain natriuretic peptide levels or heart failure admission within 1 year, estimated glomerular filtration rate > 30 mL/minute, serum creatinine < 2.5 mg/dL (or < 2 mg/dL in women), and potassium < 5 mEq/L (Weak recommendation). Avoid using phosphodiesterase-5 inhibitors or nitrates to increase daily activity or quality of life (Strong recommendation). Treat comorbidities (whether cardiovascular or noncardiovascular) if safe and effective interventions exist to improve symptoms and prognosis, including diabetes, sleep disorders, atrial fibrillation, anemia, obesity, and coronary artery disease. Description clinical heart failure with preserved left ventricular ejection fraction (≥ 50%) characterized by impaired ventricular relaxation and increased diastolic stiffness1 Also called diastolic heart failure heart failure with preserved left ventricular systolic function Definitions commonly used terms heart failure - clinical syndrome with symptoms and signs due to structural or functional cardiac abnormalities that lead to elevated intracardiac pressures or decreased cardiac output at rest or during stress (Lancet 2017 Oct 28;390(10106):1981) diastolic function - ability of the left ventricle to fill with blood from the left atrium after the mitral valve has opened (Int J Cardiol 2015 Jan 20;179:430) diastolic dysfunction - includes reduced relaxation of the left ventricle and increased diastolic stiffness1 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) definitions of heart failure classification2 heart failure with reduced ejection fraction (HFrEF) ejection fraction ≤ 40% also called systolic heart failure most randomized trial evidence is specific to patients with HFrEF heart failure with preserved ejection fraction (HFpEF) typically ejection fraction ≥ 50% also called diastolic heart failure important to consider and exclude other potential noncardiac causes of symptoms suggestive of heart failure beyond symptom management with diuresis, and management of known predisposing risks and comorbid conditions, no specific therapies yet proven to reduce mortality subsets of HFpEF include borderline HFpEF (also called heart failure with midrange ejection fraction [HFmrEF]) increasingly considered specific entity instead of subgroup of HFpEF ejection fraction 41%-49% intermediate group with characteristics, treatment patterns, and outcomes similar to patients with HFrEF often treated similarly as HFrEF, but patients often included in studies evaluating treatment for HFpEF instead improved HFpEF (also called heart failure with recovered ejection fraction [HFrecEF], heart failure with improved rejection fraction [HFiEF], or heart failure with better ejection fraction) increasingly considered specific entity instead of subgroup of HFpEF defined as ejection fraction > 40% after previously having HFrEF by ACCF/AHA guidelines; sometimes defined using different thresholds (such as ejection fraction ≥ 50% after previously having ejection fraction < 50%) subsets of HFpEF include borderline HFpEF ejection fraction 41%-49% intermediate group with characteristics, treatment patterns, and outcomes similar to patients with HFrEF treated according to guidelines for HFrEF improved HFpEF also called heart failure with recovered ejection fraction (HFrecEF) heart failure with improved rejection fraction (HFiEF) heart failure with better ejection fraction definitions of improved HFpEF vary ACCF/AHA guidelines define as ejection fraction > 40% after previously having HFrEF (ejection fraction ≤ 40%) sometimes defined using other thresholds (such as ejection fraction ≥ 50% after previously having ejection fraction < 50%) reported in 9%-72% of patients with HFrEF depending on underlying cardiomyopathy reported rates 60%-100% of patients with recent onset cardiomyopathy due to causes such as tachycardia, Takotsubo, and hyperthyroidism 40%-50% of patients with acute myocarditis, peripartum cardiomyopathy, tachycardia-induced cardiomyopathy, and some forms of cancer therapeutics-related dysfunction reported to occur less commonly in patients with chronic HFrEF factors associated with improvement in LVEF after having HFrEF may include younger age female gender higher systolic blood pressure nonischemic causes of heart failure shorter duration of heart failure less severe adverse cardiac remodeling at initial evaluation clinical features despite improved or even normalized LVEF after previously having HFrEF, patients may have functional impairment and abnormal biomarkers improvement in LVEF may not necessarily indicate recovery from underlying structural cardiomyopathic processes biochemical and clinical profile more favorable than with HFrEF, including typically classified as NYHA class I or II clinical differences from HFrEF younger age and lower prevalence of comorbidities (such as coronary artery disease, diabetes, hypertension, and atrial fibrillation) higher systolic blood pressure and smaller left ventricular volumes lower levels of biomarkers (B-natriuretic peptide, troponin), but typically higher than in healthy controls better quality of life, although heart failure symptoms often persist reduced exercise capacity compared to healthy controls generally accompanied by smaller ventricular volumes than in patients with HFrEF but greater volumes than in patients with HFpEF, which may indicate residual adverse remodeling management ACCF/AHA guidelines specify treatment according to HFrEF guidelines continuation of heart failure medications after recovery of ejection fraction suggested, specifically beta blockers, ACE inhibitors, and angiotensin receptor blockers periodic follow-up including echocardiography required, especially if cessation of medication is considered

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उपयोगी जानकारी हेतु आभार व्यक्त करता हूं।

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