From the Guidelines
The patient should be treated with diuretics, such as furosemide 20-40mg daily, to reduce fluid overload and relieve edema and shortness of breath, as recommended by the ACC/AHA guidelines 1. The cardiac echo findings in this 87-year-old female with leg edema and shortness of breath suggest heart failure with preserved ejection fraction (HFpEF). The patient has normal left ventricular systolic function (EF 65%), but shows grade I diastolic dysfunction, left atrial enlargement, mild pulmonary hypertension, and mild to moderate tricuspid regurgitation. Some key points to consider in the management of this patient include:
- Blood pressure control is essential, with a target below 130/80 mmHg using ACE inhibitors or ARBs if tolerated, as recommended by the ACC/AHA guidelines 1.
- Sodium restriction to less than 2g daily and fluid restriction to 1.5-2L daily are recommended to reduce fluid overload.
- Regular monitoring of electrolytes, especially potassium and renal function, is necessary when using diuretics. The diastolic dysfunction indicates impaired relaxation of the left ventricle, causing increased filling pressures that back up into the pulmonary circulation and right heart, explaining the pulmonary hypertension and tricuspid regurgitation. These findings, combined with the preserved ejection fraction, are consistent with HFpEF, which is common in elderly females with hypertension, as noted in the ACC/AHA guidelines 1 and the European Association of Cardiovascular Imaging recommendations 1. The use of echocardiography in the evaluation of dyspnea in patients with clinical findings suggestive of significant coronary, valvular, or hypertensive heart disease is also supported by the ACC/AHA guidelines 1. Overall, the management of this patient should focus on symptom management and reducing fluid overload, with careful monitoring of electrolytes and renal function.
From the Research
Patient Presentation
The patient, an 87-year-old female, presents with leg edema and shortness of breath (SOB). The cardiac echo results show:
- Normal left ventricular systolic function with an ejection fraction of 65%
- Grade I diastolic dysfunction
- Normal right ventricular systolic function
- Enlarged left atrial chamber dimension
- Mild pulmonary hypertension with an estimated pulmonary arterial systolic pressure of 37 mmHg
- No pericardial effusion
- Mild to moderate tricuspid valve regurgitation
Diagnosis
Based on the patient's symptoms and echo results, the diagnosis is likely heart failure with preserved ejection fraction (HFpEF), also known as diastolic heart failure 2, 3, 4. HFpEF is characterized by the presence of heart failure symptoms, normal or near-normal left ventricular ejection fraction, and evidence of diastolic dysfunction.
Key Features of HFpEF
- More common in women and older adults 2, 3
- Often associated with comorbidities such as hypertension, diabetes mellitus, and obesity 2
- Diagnosis is best achieved by two-dimensional and Doppler echocardiography, which can detect abnormal myocardial relaxation, decreased compliance, and increased filling pressure in the setting of normal left ventricular dimensions and preserved ejection fraction 2, 5
- Imaging findings may include left ventricular hypertrophy, diastolic dysfunction, left atrial enlargement, and elevated pulmonary artery pressure 5
Treatment
Treatment of HFpEF is primarily focused on managing symptoms and comorbidities, as there is no evidence-based treatment that improves clinical outcomes 2, 3, 6. Pharmacological therapy may include:
- Diuretics to prevent pulmonary congestion 3
- Angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers to reduce blood pressure and improve diastolic function 2
- Beta-blockers to lower heart rate and prolong left ventricular diastolic filling time 2
- Treatment of underlying conditions such as hypertension and atrial fibrillation 3, 4