What is the management plan for a patient with mild elevation of left ventricular end diastolic pressure, preserved left ventricular systolic ejection, no significant coronary artery disease, and endothelial dysfunction?

Management of a Patient with Mild Elevation of Left Ventricular End-Diastolic Pressure, Preserved Systolic Function, and Endothelial Dysfunction

For patients with mild elevation of left ventricular end-diastolic pressure, preserved systolic function, and endothelial dysfunction without significant coronary artery disease, the recommended management includes lifestyle modifications, blood pressure control targeting <130 mmHg systolic, and consideration of SGLT2 inhibitors as first-line therapy to improve diastolic function and reduce heart failure hospitalizations.

Diagnosis Assessment

Based on the cardiac catheterization findings, this patient has:

1. Mild elevation of left ventricular end-diastolic pressure (LVEDP) of 24 mmHg
2. Preserved left ventricular systolic function (ejection fraction 55%)
3. No significant coronary artery disease
4. Evidence of endothelial dysfunction (slow clearing of dye in the right circumflex artery)

These findings are consistent with Heart Failure with Preserved Ejection Fraction (HFpEF), which is characterized by:

• Clinical symptoms of heart failure
• LVEF ≥50%
• Evidence of diastolic dysfunction or elevated filling pressures
• Absence of significant coronary stenosis 1

Pharmacological Management

First-Line Therapy

• SGLT2 inhibitors (empagliflozin 10mg daily or dapagliflozin 10mg daily) should be initiated regardless of diabetes status, as they have been shown to reduce heart failure hospitalizations and improve quality of life in HFpEF patients 1

Blood Pressure Management

• Target systolic blood pressure <130 mmHg 1
• Preferred agents:
  • ACE inhibitors or ARBs for hypertensive patients with HFpEF 1
  • Beta-blockers for rate control if needed and for hypertension management 1

Symptom Management

• Diuretics (loop diuretics such as furosemide) should be used for symptom relief if the patient has evidence of volume overload 1
  • Initial dose: 20-40mg
  • Usual daily dose: 40-240mg
  • Aim to achieve euvolemia with the lowest effective dose

For Diuretic Resistance

• Consider adding thiazide diuretics or mineralocorticoid receptor antagonists (MRAs) like spironolactone 25mg daily 1

Lifestyle Modifications

• Regular aerobic exercise is strongly recommended to improve functional capacity 1
• Moderate sodium restriction (2-3g/day) 1
• Weight reduction in overweight/obese patients (target ≥5-10% weight loss) 1
• Smoking cessation if applicable 2
• Enrollment in cardiac rehabilitation program 2

Monitoring and Follow-up

1. Regular monitoring of:

   • Symptoms
   • Volume status
   • Weight
   • Renal function
   • Electrolytes 1

2. Adjust diuretic dose based on symptoms and weight measurements

3. Repeat echocardiography if there are significant changes in clinical status 1

4. Monitor electrolytes and renal function 1-2 weeks after initiation or dose changes of RAAS inhibitors 1

5. Avoid nephrotoxic medications such as NSAIDs 1

Special Considerations for Endothelial Dysfunction

Endothelial dysfunction, as evidenced by slow clearing of contrast in the coronary arteries, is an important finding that warrants specific attention:

• Statins should be initiated regardless of baseline lipid levels, targeting LDL-C <1.8 mmol/L (<70 mg/dL) 2
• Consider ACE inhibitors specifically for their beneficial effects on endothelial function 2

Management Algorithm

1. Initial Assessment:

   • Confirm diagnosis with echocardiographic parameters of diastolic dysfunction
   • Assess for comorbidities (hypertension, diabetes, obesity)
   • Evaluate volume status

2. First-line Therapy:

   • Start SGLT2 inhibitor (empagliflozin 10mg daily or dapagliflozin 10mg daily)
   • Initiate statin therapy for endothelial dysfunction

3. Blood Pressure Management:

   • If hypertensive, start ACE inhibitor or ARB
   • Target systolic BP <130 mmHg

4. Volume Management:

   • If signs of volume overload, start loop diuretic (furosemide)
   • Titrate to achieve euvolemia

5. Lifestyle Modifications:

   • Prescribe regular aerobic exercise
   • Recommend sodium restriction
   • Weight loss if overweight/obese

6. Follow-up:

   • Monitor symptoms, weight, renal function, and electrolytes
   • Adjust medications as needed
   • Consider repeat echocardiography with clinical changes

Common Pitfalls to Avoid

1. Overdiuresis: Excessive diuresis can lead to hypotension and worsening renal function. Aim for the lowest effective dose.

2. Ignoring endothelial dysfunction: This is an important finding that should be addressed with statins and ACE inhibitors.

3. Focusing solely on systolic function: Despite preserved ejection fraction, these patients require active management of diastolic dysfunction.

4. Overlooking comorbidities: Conditions like hypertension, diabetes, and obesity can worsen HFpEF and should be aggressively managed.

5. Failing to emphasize lifestyle modifications: Exercise and sodium restriction are cornerstone therapies in HFpEF management.