History and exam
Key diagnostic factors
common
presence of risk factors
Key risk factors include hypertension, female sex, age >70 years, obesity, coronary artery disease/ischaemia, diabetes mellitus, and chronic kidney disease.
exertional dyspnoea
Exertional dyspnoea is common in patients with HFpEF but is not unique to heart failure, and so it is crucial to take a detailed history and comprehensive assessment of patients with dyspnoea.[58]
Other diagnostic factors
common
orthopnoea
Orthopnoea is defined as dyspnoea in the recumbent position that usually occurs within a few minutes after recumbency while the patient is awake. This is a non-specific symptom, as it may occur in any condition that causes a reduced pulmonary vital capacity.
paroxysmal nocturnal dyspnoea
Dyspnoea that occurs while a patient is asleep, waking up suddenly with a feeling of suffocation.
It is more specific to heart failure than orthopnoea.
abdominal fullness
Swelling or pain in the upper abdomen is caused by fluid retention and hepatic/intestinal congestion. Some patients notice that their clothes feel tighter or that they struggle to do up their trousers.
Related to abdominal congestion.
rales
Usually bilateral and in the basal segments. If unilateral, it is usually on the right side and associated with a pleural effusion. It is important to rule out lung pathology such as an infection, consolidation, or interstitial fibrosis.
jugular venous distension
This is measured at a 45-degree angle, jugular venous pressure above 5 cm from the sternal angle is considered elevated, and roughly corresponds to a right atrial pressure of 10 cmH₂0.
hepatojugular reflux
Jugular venous pressure may be normal at rest, but rises to abnormal levels with increased right upper quadrant pressure by the manoeuvre of firm pressure over the liver.
congestive hepatomegaly
Usually develops before overt oedema occurs and is associated with abnormal liver function tests.
lower extremity oedema
Usually bilateral and pitting. This results in reduced mobility as patients find walking very difficult. In some patients, there is sacral oedema or even oedema in the lumbar or thoracic region. Patients with such extensive oedema normally need to be admitted for intravenous diuretic therapy.
laterally displaced apical impulse
A laterally displaced apical impulse on physical examination suggests cardiomegaly.
uncommon
gallop sounds
An S3 gallop, which occurs after the second heart sound, has been shown to be an independent predictor of death and hospitalisation due to heart failure. An S4 is heard in patients with hypertensive heart disease, which is usually the setting for diastolic dysfunction. However, it is non-specific, as it may be heard in a variety of other conditions, including coronary artery disease.
Risk factors
strong
hypertension
Hypertension is the most important risk factor for HFpEF, with a prevalence of 60% to 89%.[2][4] It is a more common comorbidity in patients who have HFpEF than in those with reduced ejection fraction (HFrEF).[16] Abnormalities of left ventricular diastolic filling have been noted in adult patients with isolated diastolic, isolated systolic, and combined systolic and diastolic hypertension.[25] Changes in intrinsic myocardial stiffness, myocardial fibrosis with interstitial collagen deposition, and altered chamber geometry are other possible mechanisms for diastolic dysfunction in patients with hypertension.[25]
Hypertension is associated with left atrial enlargement, depression of atrial contractile function, and increased risk for atrial fibrillation, which contributes to heart failure (HF).
atrial fibrillation (AF)
AF and HF are often comorbid, and either may cause or exacerbate the other.[4] It is more common in patients who have HFpEF than in those with HFrEF.[2] AF increases the risk of thrombo-embolic events (e.g., stroke) and may lead to a worsening of symptoms. Development of atrial fibrillation in patients with HF is associated with a worse prognosis; however, those who develop atrial fibrillation first may have a more favourable clinical course.[4][26]
Atrial systole contributes up to 40% of diastolic filling, so atrial fibrillation with a resultant loss of 'atrial kick' can precipitate overt HF in patients with underlying ventricular diastolic dysfunction.[25][27][28]
female sex
age >70 years
Patients >70 years of age are more likely to have HFpEF than heart failure with a reduced ejection fraction.[30] The mean age of patients with HFpEF ranges from 60 to 78 years.[31] In the general population, the proportion with diastolic dysfunction sharply increases after age 65 years in both sexes.[32]
obesity
Up to 80% of people with HFpEF are reported to be overweight or have obesity.[2] Obesity is one of the strongest risk factors for HFpEF; it is both an independent risk factor and is also associated with other comorbidities, such as hypertension and diabetes.[2] Obesity is associated with left ventricular (LV) hypertrophic remodelling, increased myocardial stiffness, and ventricular dysfunction.[33] In children and adolescents, obesity (measured by BMI) is associated with impaired LV diastolic function.[34] Central obesity, as measured by waist-hip ratio, correlates better with diastolic function and mortality than BMI.[35]
coronary artery disease (CAD)/ischaemia
CAD is one of the most important risk factors for HF, particularly HFrEF, and is also a common comorbidity in patients with HFpEF.[2][36] In the ARIC (Atherosclerosis Risk in Communities) study, CAD was found to be a significant risk factor for incident HFpEF after adjustment for demographics and common comorbidities.[36] Patients with suggestive symptoms should be assessed for possible coronary disease as a cause of HF and to guide management.[2]
diabetes mellitus
Approximately 45% of patients with HFpEF have diabetes mellitus, and the prevalence is reported to be increasing most significantly in those with new-onset HFpEF.[37] The presence of comorbid diabetes in patients with HFpEF is associated with an increased risk of morbidity and mortality compared with those without diabetes.[37][38]
Both type 1 and type 2 diabetes increase the risk of developing HF across the entire range of glucose levels; however, HF may be more prevalent in people with type 1 compared with type 2 diabetes.[39]
chronic kidney disease (CKD)
dyslipidaemia
Lipid abnormalities have been linked to increased risk for HF; they are common comorbidities.[44]
exposure to cardiotoxic agents
Chemotherapeutic agents, particularly anthracyclines (e.g., doxorubicin, daunorubicin), are associated with an increased risk of HF.[45]
metabolic syndrome or cardiovascular-kidney-metabolic (CKM) syndrome
Metabolic syndrome is a cluster of common conditions, including insulin resistance, impaired glucose tolerance, abdominal obesity, reduced high-density lipoprotein-cholesterol levels, elevated triglycerides, and hypertension. Metabolic syndrome and the individual components are risk factors for development and progression of HF.[46] CKM syndrome is a disorder defined by the American Heart Association (AHA) to reflect the connections between metabolic disease (obesity, diabetes, metabolic syndrome), kidney disease, and cardiovascular disease (CVD).[47][48] It includes both individuals at risk for CVD (due to the presence of metabolic risk factors, CKD, or both) and individuals with existing CVD. Poor CKM health affects nearly all organ systems and is associated with cardiovascular morbidity and mortality. The AHA has proposed a CKM syndrome staging system based on patient risk factors and opportunities for prevention and care. The AHA recommends that these patients are managed by an interdisciplinary team with targeted referral of high-risk CKM patients to appropriate subconsultants.[47]
weak
myocardial and pericardial disorders
These conditions decrease left ventricular compliance and impair relaxation, thus increasing left ventricular filling pressures.
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