Cardiac Imaging in Patients With Heart Failure and Preserved Ejection Fraction
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A 65-year-old female with hypertension and diabetes mellitus presented with progressive dyspnea that now occurs with daily activities. The patient has orthopnea and recurrent episodes of wheezing. By examination, her body mass is 220 lbs with a heart rate of 86 bpm and blood pressure of 160/98 mm Hg. Jugular venous pressure was 12 cms, and bilateral pitting edema was noted to the knee level. Point of maximum impulse was located in the left fifth intercostal space mid-clavicular line and P2 was accentuated. Chest radiograph showed central pulmonary congestion, but there were no pulmonary infiltrates. Electrocardiogram showed sinus rhythm with voltage criteria for left ventricular (LV) hypertrophy and strain pattern. Clinical presentation is consistent with heart failure given the signs and symptoms of systemic and pulmonary congestion, although additional testing is reasonable given the presence of wheezing. There are several questions to answer pertaining to LV and right ventricular (RV) size and systolic function, LV diastolic function, left atrial (LA) volumes, pulmonary artery (PA) pressures, and ultimately given the absence of apical displacement whether this patient has heart failure with preserved ejection fraction (HFpEF) or not.
Definition of HFpEF
In addition to symptoms, HFpEF is diagnosed in the presence of a preserved ejection fraction (EF). There are several cutoffs that have been used to define a preserved EF. Some clinical trials have taken an EF >40% to meet this definition, whereas others have used values of 45% or 50%. Recent guidelines defined preserved EF as LV EF ≥50%.1 They have also recognized that patients with an EF of 40% to 49% represent an intermediate group, which was termed HFmrEF.1 Although this classification is not accepted by all, it is still useful because therapeutic decisions and diagnostic workups depend on EF.
LV volumes are usually normal, and patients may have concentric LV …