What is the cause of recurrent pleural effusion in a patient with heart failure with preserved Ejection Fraction (EF)?

From the Guidelines

The primary cause of recurrent pleural effusion in a patient with heart failure with preserved Ejection Fraction (EF) is elevated left ventricular filling pressures leading to pulmonary venous hypertension, which increases hydrostatic pressure and drives fluid into the pleural space, as supported by the most recent evidence from 1.

Management Approach

The management of repeated pleural effusions in patients with heart failure with preserved ejection fraction (HFpEF) should focus on optimizing heart failure treatment while addressing the effusions directly.

• The primary approach involves diuretic therapy with loop diuretics such as furosemide (20-80 mg daily) or torsemide (10-40 mg daily), which can be increased as needed to manage fluid overload, as suggested by 1.
• For persistent effusions, adding a thiazide diuretic like metolazone (2.5-5 mg) or chlorthalidone (12.5-25 mg) can enhance diuresis through sequential nephron blockade.
• Sodium restriction (less than 2-3 g daily) and fluid restriction (1.5-2 L daily) are important supportive measures.

Addressing Recurrent Effusions

For symptomatic relief of large effusions, therapeutic thoracentesis may be necessary, though this addresses symptoms rather than the underlying cause.

• In recurrent cases refractory to medical management, consider indwelling pleural catheters or pleurodesis, as discussed in 1.
• The use of sodium-glucose co-transporter 2 (SGLT2) inhibitors has shown promise in reducing composite cardiovascular death or HF hospitalizations in patients with HFpEF, as noted in 1.

Underlying Mechanism

The underlying mechanism involves elevated left ventricular filling pressures in HFpEF leading to pulmonary venous hypertension, which increases hydrostatic pressure and drives fluid into the pleural space.

• This is exacerbated by decreased oncotic pressure from hypoalbuminemia and increased vascular permeability from inflammation, both common in heart failure.
• Optimizing heart failure treatment and addressing comorbidities are crucial in managing recurrent pleural effusions in HFpEF patients, as emphasized by 1.

From the Research

Causes of Recurrent Pleural Effusion in HFpEF

• Recurrent pleural effusion in patients with heart failure with preserved ejection fraction (HFpEF) can be caused by various factors, including fluid retention and congestion 2, 3, 4, 5, 6
• The pathophysiology of HFpEF is complex and involves both cardiac and non-cardiac mechanisms, which can lead to fluid accumulation in the pleural space 2, 4
• Comorbidities such as hypertension, diabetes, dyslipidemia, and obesity can also contribute to the development of pleural effusion in HFpEF patients 5

Diagnosis and Management of HFpEF

• Diagnosis of HFpEF can be challenging due to the presence of multiple comorbidities and alternative reasons for dyspnea and exercise intolerance 3, 4
• A stepwise approach to diagnosis and treatment, including clinical evaluation, invasive diagnostic testing, and risk factor modification, can help improve outcomes in HFpEF patients 3
• Treatment of HFpEF focuses on managing symptoms and comorbidities, as well as optimizing risk factors, and may include pharmacologic therapies such as sodium-glucose cotransporter 2 inhibitors and diuretics 2, 5, 6

Specific Causes of Pleural Effusion in HFpEF

• Valvular, infiltrative, or pericardial disease can also cause pleural effusion in HFpEF patients and should be identified and treated accordingly 5
• Exercise training, diet-induced weight loss, and education in HF self-care can help improve functional capacity and quality of life in HFpEF patients 5