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Chapter 1 1. a. Cardiac relaxation is regulated by NO. ROS can affect NO-related signaling at multiple sites. NO is generated by NO synthase (NOS), which requires tetrahydrobiopterin as a cofactor for the reaction. Hypertension and activation of the renin-angiotensin system lead to a depletion of tetrahydrobiopterin. 2. c. Transcriptional control of mRNA encoding procollagen I is one mechanism by which levels of secreted procollagen can increase. Procollagen…
Cases of Diastolic Heart Failure
Case 1 35-Year-Old African American Man With Suspected Left Ventricular Hypertrophy History: 35-year-old African American athlete referred for evaluation of suspected left ventricular hypertrophy based on an electrocardiogram (ECG) obtained during his annual screening. He is otherwise completely asymptomatic. Past medical history: None Past surgical history: Fractured left tibia Social: Denies any smoking or alcohol consumption Physical exam: Pulse: 47 bpm, sinus rhythm Blood pressure: 120/75…
Future Therapies in HFpEF
Introduction The treatment of diastolic heart failure (HF), also known as heart failure with preserved systolic function (HFpEF), has been challenging, partly because there is a lack of consensus regarding the definition of the disease entity as well as a paucity of large-scale clinical trials to demonstrate effective therapeutic strategies. Diastolic and systolic HF may have certain similar pathophysiologic processes in common, but there are also…
Echo-Based Approach to the Management of Heart Failure With Preserved Ejection Fraction
Case Study A 76-year-old female with a history of heart failure with preserved ejection fraction (HFpEF), type 2 diabetes mellitus, obesity, hypertension, and chronic back pain is referred to you from her primary care provider. She was diagnosed with HFpEF approximately 2 years ago and has been hospitalized once in the past year for a presumed HF exacerbation. She reports progressively worse dyspnea on exertion and…
General Treatment of Heart Failure With Preserved Ejection Fraction and Randomized Trials
Case Study A 45-year-old male presents for a 1-month follow-up visit after an index hospitalization for dyspnea and peripheral edema, at which time he was found to be hypertensive. He has no known diabetes or coronary artery disease (CAD). His only medication is amlodipine 5 mg daily. On physical examination, body mass index (BMI) is 38 kg/m 2 , blood pressure 160/88 mmHg, and heart rate…
Pulmonary Hypertension in Heart Failure With Preserved Ejection Fraction
Abbreviations HFpEF heart failure with preserved ejection fraction HFrEF heart failure with reduced ejection fraction mPAP mean pulmonary arterial pressure PA pulmonary arterial/artery PCWP pulmonary capillary wedge pressure PH pulmonary hypertension PVR pulmonary vascular resistance RV right ventricle / right ventricular TAPSE tricuspid annular plane systolic excursion Case Study A 66-year-old woman with long-standing systemic hypertension, obstructive sleep apnea, coronary artery disease, atrial fibrillation, and chronic…
Perioperative Assessment of Diastolic Function
Case Study A 75-year-old female presents for coronary artery bypass grafting (CABG) for treatment of unstable angina secondary to severe three-vessel coronary artery disease. The patient reports a history of hypertension, hyperlipidemia, and diabetes mellitus. Preoperative transthoracic echocardiogram demonstrated normal left ventricular (LV) and right ventricular (RV) systolic function, left atrial (LA) enlargement, mild mitral regurgitation (MR), and no evidence of pulmonary hypertension. Preoperative laboratory assessment…
Aging and Heart Failure With Preserved Ejection Fraction
Case Study A 68-year-old woman with a history of hypertension (HTN) presents to clinic with dyspnea on exertion. She is an avid gardener and has been unable to keep up with her weeding over the past few years. Otherwise, she is mostly sedentary. Her blood pressure (BP) is mildly elevated at 145/70 mmHg, pulse is 75 bpm, and oxygen saturation is 99%. On exam, she has…
Chronotropic Incompetence and Pacing in HPEF Heart Failure with Preserved Ejection Fraction
Case Study A 70-year-old female with a history of hypertension, hyperlipidemia, paroxysmal atrial fibrillation (AFib), and complete heart block with a dual chamber permanent pacemaker implanted 10 years prior presented to the cardiology clinic with exertional dyspnea and fatigue for evaluation. Within the last year the patient had received a diagnosis of nonischemic cardiomyopathy (NICM) with an ejection fraction (EF) of 25%. Diagnostic coronary angiogram was…
Global and Regional Systolic Function of the Left Ventricle
Case Study An 82-year-old male presents to the office complaining of several months of shortness of breath and cough after walking two blocks or up a flight of stairs. He has also noted leg swelling and occasional palpitations. Past medical history is remarkable for hypertension, type 2 diabetes, lumbar spinal stenosis, and carpal tunnel syndrome. On physical exam, the blood pressure (BP) is 150/90 mmHg and…
Diabetes Mellitus
Case Study A 65-year-old male presents with exertional dyspnea for investigation. He states his dyspnea worsens when walking up a hill. For history, he has type 2 diabetes (treated with metformin), hypertension, dyslipidemia, and Barrett’s esophagus. He previously had an elective percutaneous coronary intervention (PCI) for a positive exercise stress test (indication: exertional dyspnea). Introduction Diabetes is a complex, chronic illness requiring continuous medical care with…
Diastolic Function in Children and in Children With Congenital Heart Disease
Case Study A 14-year-old boy presented following a sudden cardiac arrest (likely ventricular fibrillation) and was direct current (DC) cardioverted. Based on his clinical presentation and echocardiogram he was diagnosed with restrictive cardiomyopathy (RCM). Family history was negative. He was assessed for heart transplant, but the family decided not to proceed with transplant. He underwent placement of an intracardiac defibrillator and was started on a beta…
Pericardial Diseases: Constrictive Pericarditis and Pericardial Effusion
Case Study A 69-year-old man presented with progressive leg edema, abdominal fullness, shortness of breath, and 30-lb weight gain over the course of 24 months. Past medical history included hypertension and hyperlipidemia on medical therapy. He denied any history of rheumatologic disorder, previous radiation therapy, or cardiothoracic surgery. Physical exam revealed markedly elevated venous pressure ( Video 26.1 ) with prominent x and y descents. Cardiac…
Hypertrophic Cardiomyopathy
Diastolic Function in Hypertrophic Cardiomyopathy Hypertrophic cardiomyopathy (HCM) is a primary autosomal dominant disorder of the myocardium caused by mutations in several genes encoding cardiac contractile proteins ( Fig. 25.1 ). Alterations in myocardial structure at both a macroscopic and a microscopic level occur in the form of myocardial hypertrophy, fiber disarray, increased loose connective tissue and fibrosis, and abnormalities of the coronary microvasculature, with the…
Coronary Artery Disease
Introduction While coronary artery disease (CAD) and hypertension are common comorbidities in diastolic dysfunction, and heart failure with preserved ejection fraction (HFpEF), relatively less attention has been paid to the interaction between CAD and diastolic dysfunction. This chapter is devoted to reviewing how diastolic dysfunction and coronary disease relate, the assessment of diastolic function in patients with coronary disease, and the role of Doppler echocardiography in…
Primary Restrictive, Infiltrative, and Storage Cardiomyopathies
Introduction A classification serves to bridge the gap between ignorance and knowledge. J.F. Goodwin Historically, restrictive cardiomyopathies were among the three primary forms of idiopathic heart muscle diseases, characterized by the World Health Organization as “restrictive filling and reduced diastolic volume of either or both ventricles with normal or near-normal systolic function.” This early grouping of cardiomyopathies highlighted the readily evident morphologic and functional features of…
Stage D Heart Failure With Preserved Ejection Fraction, Heart Transplantation, and Mechanical Circulatory Support
Definition of Stage D Heart Failure The American College of Cardiology (ACC) and American Heart Association (AHA) guideline for the management of heart failure (HF) classifies disease progression into four stages. Stage A includes patients with risk factors for HF but without structural heart disease, stage B includes those with structural heart disease without HF symptoms, stage C represents symptomatic HF associated with underlying structural heart…
Valve Disease
Introduction Mild degrees of valvular heart disease are very prevalent in adult patients with heart failure symptoms. Given that these are often patients with hypertension, aortic valve sclerosis and mitral annular calcification, frequently accompanied by some degree of mitral regurgitation, are extremely common. They need to be taken into consideration when assessing such patients. On the other hand, severe left-sided valvular heart disease may also lead…
Hypertension and Its Relation to Heart Failure With a Preserved Ejection Fraction
Introduction Hypertension (HTN) is the single most important and widespread cardiovascular diagnosis in the developed world and, as such, an enormous public health problem. With the recent change in guidelines reducing the systolic blood pressure (BP)–lowering target from 140 to 130 mmHg based on the landmark Systolic Blood Pressure Intervention Trial (SPRINT), it is now estimated that 46% of Americans should be considered to have treatable…