Skip to main content

Main menu

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • Classified ads
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN

User menu

Search

  • Advanced search
CMAJ
  • CMAJ JOURNALS
    • CMAJ Open
    • CJS
    • JAMC
    • JPN
CMAJ

Advanced Search

  • Home
  • COVID-19
    • Articles & podcasts
    • Blog posts
    • Collection
    • News
  • Content
    • Current issue
    • Past issues
    • Early releases
    • Collections
    • Sections
    • Blog
    • Infographics & illustrations
    • Podcasts
    • Classified ads
  • Authors
    • Overview for authors
    • Submission guidelines
    • Submit a manuscript
    • Forms
    • Editorial process
    • Editorial policies
    • Peer review process
    • Publication fees
    • Reprint requests
  • CMA Members
    • Overview for members
    • Earn CPD Credits
    • Print copies of CMAJ
    • Career Ad Discount
  • Subscribers
    • General information
    • View prices
  • Alerts
    • Email alerts
    • RSS
  • JAMC
    • À propos
    • Numéro en cours
    • Archives
    • Sections
    • Abonnement
    • Alertes
  • Visit CMAJ on Facebook
  • Follow CMAJ on Twitter
  • Follow CMAJ on Pinterest
  • Follow CMAJ on Youtube
  • Follow CMAJ on Instagram
Practice

A 70-year-old woman with heart failure with preserved ejection fraction

Prashant Sharma and Vijaiganesh Nagarajan
CMAJ April 21, 2015 187 (7) 510-511; DOI: https://doi.org/10.1503/cmaj.131742
Prashant Sharma
Department of Hospital Internal Medicine (Sharma), Mayo Clinic, Rochester, Minn.; Department of Cardiovascular Medicine (Nagarajan), University of Virginia, Charlottesville, Va.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: sharma.prashant@mayo.edu
Vijaiganesh Nagarajan
Department of Hospital Internal Medicine (Sharma), Mayo Clinic, Rochester, Minn.; Department of Cardiovascular Medicine (Nagarajan), University of Virginia, Charlottesville, Va.
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Tables
  • Related Content
  • Responses
  • Metrics
  • PDF
Loading

See also page 518 and www.cmaj.ca/lookup/doi/10.1503/cmaj.140430

A 70-year-old woman was referred to her family physician by the emergency department for follow-up of shortness of breath, orthopnea and swelling of her legs that she had experienced for two months. She had no other symptoms and was taking amlodipine 10 mg daily and lisinopril 10 mg daily for hypertension. On physical examination, her blood pressure was 160/92 mm Hg and pulse rate was 70 beats/min. Estimated central venous pressure was 12 (normal ≤ 8) cm H2O. Cardiac examination was unremarkable, and there were bibasilar crackles on lung auscultation. She had bilateral pedal pitting edema. In the emergency department, test results for electrolyte levels and renal function were within normal limits. An electrocardiogram showed sinus rhythm and left ventricular hypertrophy. An echocardiogram showed an ejection fraction of 56%, concentric left ventricular hypertrophy with no substantial valvular abnormalities, and grade III diastolic dysfunction.

What is the diagnosis?

Based on the presenting symptoms and examination findings, the clinical syndrome of heart failure was diagnosed. Heart failure is a clinical diagnosis. Once the diagnosis is made, ejection fraction measured by echocardiography helps to distinguish between different types of heart failure (Box 1).1

Box 1:

Types of heart failure based on left ventricular ejection fraction1

View this table:
  • View inline
  • View popup
  • Download powerpoint

Diagnosis of heart failure with preserved ejection fraction is challenging, because other potential causes of symptoms have to be excluded. Most patients with heart failure with preserved ejection fraction have evidence of abnormal left ventricular diastolic function on Doppler echocardiography.1,2 In the past, heart failure with preserved ejection fraction was commonly called “diastolic heart failure.” Because left ventricular diastolic dysfunction is seen not only in patients with heart failure with preserved ejection fraction, but also in those with heart failure with reduced ejection fraction, “heart failure with preserved ejection fraction” has replaced “diastolic heart failure.”1,3 About 40%–70% of patients with clinical heart failure have heart failure with preserved ejection fraction.1 Among the patients admitted to hospital with decompensated heart failure, the proportion of those with heart failure with preserved ejection fraction has been increasing over the last 15 years.4,5

Heart failure with preserved ejection fraction and heart failure with reduced ejection fraction are two distinct syndromes and do not represent a continuous spectrum of disorder. They differ in several aspects, including pathophysiology, patient population and treatment modalities.1,2 Pathophysiology of heart failure with preserved ejection fraction is related to diastolic dysfunction, and major predictors are left ventricular relaxation and stiffness.2,3

Our patient had clinical features of heart failure but had normal left ventricular ejection fraction, and therefore was given the diagnosis of heart failure with preserved ejection fraction.

What risk factors may have contributed to heart failure in this patient?

The major predictors of heart failure with preserved ejection fraction are hypertension, atrial fibrillation, older age, female sex, coronary artery disease, obesity, diabetes and hyperlipidemia.1 Of these risk factors, hypertension is the most frequent, with prevalence of up to 90%.1,2 Also, heart failure with preserved ejection fraction is associated with multiple noncardiac comorbidities, such as chronic kidney disease, lung disease, anemia, liver disease and thyroid diseases.

Our patient had a history of long-standing hypertension, which likely contributed to the development of heart failure with preserved ejection fraction.

What treatment options should be considered for this patient?

Treatment for patients with heart failure with preserved ejection fraction mainly involves risk-factor modification and treatment of associated comorbidities.1,2 Because trial data are limited, strict control of blood pressure and other comorbidities remain the mainstay of management.1,2 To date, no treatment has been shown to improve mortality in these patients.

Although angiotensin-converting enzyme inhibitors and β-blockers have not shown a mortality benefit in patients with heart failure with preserved ejection fraction, they should be used if indicated for comorbid conditions, such as hypertension, coronary artery disease and chronic kidney disease.1 Because hypertension, tachycardia and coronary ischemia could cause decompensation of heart failure, these conditions should be treated according to guidelines, including coronary intervention if needed.1–3

Diuretics are used for symptomatic patients with volume overload. In the recently reported Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) study, spironolactone did not decrease mortality, but was noted to decrease the rate of hospital admissions for heart failure.6

Lifestyle modification with exercise training has been shown to improve quality of life in these patients.2,7 Adherence to medication should be emphasized, and patients with multiple comorbidities should be enrolled in programs for heart failure management if available.1,2

What follow-up does this patient require?

Patients with heart failure with preserved ejection fraction should receive follow-up like those with heart failure with reduced ejection fraction. Although mortality for heart failure with preserved ejection fraction may be lower than that for heart failure with reduced ejection fraction, studies show that the rate of heart failure–related hospital admissions among patients with heart failure with preserved ejection fraction is similar to the rate among patients with heart failure with reduced ejection fraction.2,8 An efficient system of coordinated care, active patient education and appropriate follow-up is recommended for all patients with heart failure with preserved ejection fraction.1,2

Case revisited

The patient was advised to increase her lisinopril dose to achieve better blood pressure control, and she was also started on spironolactone. At two weeks’ follow-up, her shortness of breath was better and her blood pressure was 138/82 mm Hg. She was referred to a heart failure clinic for follow-up.

Footnotes

  • Competing interests: None declared.

  • This article has been peer reviewed.

  • Contributors: Both of the authors equally contributed to the drafting and revision of the manuscript, and gave final approval of the version submitted for publication.

References

  1. ↵
    1. Yancy CW,
    2. Jessup M,
    3. Bozkurt B,
    4. et al
    . 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;62:e147–239.
    OpenUrlCrossRefPubMed
  2. ↵
    1. McMurray JJ,
    2. Adamopoulos S,
    3. Anker SD,
    4. et al.
    ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2012;14:803–69.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Borlaug BA,
    2. Paulus WJ
    . Heart failure with preserved ejection fraction: pathophysiology, diagnosis, and treatment. Eur Heart J 2011;32:670–9.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Owan TE,
    2. Hodge DO,
    3. Herges RM,
    4. et al
    . Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med 2006;355:251–9.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Steinberg BA,
    2. Zhao X,
    3. Heidenreich PA,
    4. et al
    . Trends in patients hospitalized with heart failure and preserved left ventricular ejection fraction: prevalence, therapies, and outcomes. Circulation 2012;126:65–75.
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Pitt B,
    2. Pfeffer MA,
    3. Assmann SF,
    4. et al
    . Spironolactone for heart failure with preserved ejection fraction. N Engl J Med 2014;370:1383–92.
    OpenUrlCrossRefPubMed
  7. ↵
    1. Kitzman DW,
    2. Brubaker PH,
    3. Morgan TM,
    4. et al
    . Exercise training in older patients with heart failure and preserved ejection fraction: a randomized, controlled, single-blind trial. Circ Heart Fail 2010;3:659–67.
    OpenUrlAbstract/FREE Full Text
  8. ↵
    1. Quiroz R,
    2. Doros G,
    3. Shaw P,
    4. et al
    . Comparison of characteristics and outcomes of patients with heart failure preserved ejection fraction versus reduced left ventricular ejection fraction in an urban cohort. Am J Cardiol 2014;113:691–6.
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Canadian Medical Association Journal: 187 (7)
CMAJ
Vol. 187, Issue 7
21 Apr 2015
  • Table of Contents
  • Index by author

Article tools

Respond to this article
Print
Download PDF
Article Alerts
To sign up for email alerts or to access your current email alerts, enter your email address below:
Email Article

Thank you for your interest in spreading the word on CMAJ.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
A 70-year-old woman with heart failure with preserved ejection fraction
(Your Name) has sent you a message from CMAJ
(Your Name) thought you would like to see the CMAJ web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
A 70-year-old woman with heart failure with preserved ejection fraction
Prashant Sharma, Vijaiganesh Nagarajan
CMAJ Apr 2015, 187 (7) 510-511; DOI: 10.1503/cmaj.131742

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
‍ Request Permissions
Share
A 70-year-old woman with heart failure with preserved ejection fraction
Prashant Sharma, Vijaiganesh Nagarajan
CMAJ Apr 2015, 187 (7) 510-511; DOI: 10.1503/cmaj.131742
Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • What is the diagnosis?
    • What risk factors may have contributed to heart failure in this patient?
    • What treatment options should be considered for this patient?
    • What follow-up does this patient require?
    • Case revisited
    • Footnotes
    • References
  • Figures & Tables
  • Related Content
  • Responses
  • Metrics
  • PDF

Related Articles

  • Chronic heart failure with reduced ejection fraction
  • Highlights
  • PubMed
  • Google Scholar

Cited By...

  • Heart failure guidelines fail
  • Google Scholar

More in this TOC Section

  • Azathioprine-induced severe anemia potentiated by the concurrent use of allopurinol
  • Schwannoma of the tongue
  • “Superscan” in diffusion-weighted imaging with background body suppression magnetic resonance imaging
Show more Practice

Similar Articles

Collections

  • Sections
    • Decisions
  • Topics
    • Cardiology: hypertension
    • Cardiology: heart failure

Content

  • Current issue
  • Past issues
  • Collections
  • Sections
  • Blog
  • Podcasts
  • Alerts
  • RSS
  • Early releases

Information for

  • Advertisers
  • Authors
  • Reviewers
  • CMA Members
  • Media
  • Reprint requests
  • Subscribers

About

  • General Information
  • Journal staff
  • Editorial Board
  • Governance Council
  • Journal Oversight
  • Careers
  • Contact
  • Copyright and Permissions

Copyright 2021, Joule Inc. or its licensors. All rights reserved. ISSN 1488-2329 (e) 0820-3946 (p)

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries.

Powered by HighWire