What is the recommended management for a patient with an E/E' ratio of 15.96 and an ejection fraction (EF) of 58%, indicating potential heart failure with preserved ejection fraction (HFpEF)?

Management of a Patient with E/E' Ratio of 15.96 and EF of 58%: Diagnosis and Treatment of HFpEF

The patient should be diagnosed with heart failure with preserved ejection fraction (HFpEF) based on the elevated E/E' ratio of 15.96 and EF of 58%, and treatment should begin with an SGLT2 inhibitor (dapagliflozin or empagliflozin) along with diuretic therapy to manage congestion. 1

Diagnostic Confirmation

• The patient's echocardiographic findings strongly support a diagnosis of HFpEF with:

  • Preserved EF of 58% (HFpEF defined as EF ≥50%) 1
  • Elevated E/E' ratio of 15.96 (E/E' ≥15 indicates elevated LV filling pressures) 1
  • Increased relative wall thickness (RWT) of 0.44, suggesting concentric remodeling 1
  • Left atrial enlargement (4.1 cm), indicating chronic elevation of filling pressures 1
  • Short mitral deceleration time (103 ms), suggesting restrictive filling pattern 1

• These findings meet the diagnostic criteria for HFpEF according to the 2022 AHA/ACC/HFSA guidelines, which require:

  • Signs/symptoms of heart failure
  • EF ≥50%
  • Evidence of increased LV filling pressures (E/E' ≥15) 1

Management Approach

First-Line Pharmacological Therapy

• SGLT2 inhibitors should be initiated as first-line therapy:

  • Dapagliflozin or empagliflozin reduced HF hospitalization or cardiovascular death by approximately 20% in randomized trials 2
  • These medications have demonstrated benefit in the DELIVER and EMPEROR-PRESERVED trials 1
  • Start with standard dosing: empagliflozin 10 mg daily or dapagliflozin 10 mg daily 1

• Loop diuretics should be prescribed to manage congestion:

  • The elevated E/E' ratio of 15.96 indicates significant elevation in filling pressures requiring diuretic therapy 1
  • Start with furosemide 20-40 mg daily or equivalent, and titrate based on symptoms 1
  • Monitor for electrolyte abnormalities and renal function 1

Additional Pharmacological Options

• Mineralocorticoid receptor antagonists (MRAs) should be considered:

  • Spironolactone has shown benefit in selected HFpEF patients, particularly women and those with lower ejection fractions 1
  • Start with spironolactone 25 mg daily and monitor potassium and renal function 1

• ARNI (sacubitril/valsartan) may be considered in selected patients:

  • May provide benefit in women and those with LVEF below normal range 1
  • Consider in patients who remain symptomatic despite first-line therapy 1

Non-Pharmacological Management

• Exercise training should be recommended:

  • Improves functional capacity and quality of life 2
  • Start with supervised cardiac rehabilitation if available 1

• Weight loss for patients with obesity:

  • Diet-induced weight loss has shown clinically meaningful improvements in functional capacity 2
  • Target 5-10% weight reduction in obese patients 1

• Self-care education:

  • Medication adherence, dietary sodium restriction, and symptom monitoring 2
  • Daily weight monitoring to detect early fluid retention 1

Addressing Comorbidities

• Hypertension management is critical:

  • Target BP <130/80 mmHg 1
  • The patient's concentric remodeling (RWT 0.44) suggests chronic pressure overload 1

• Screen for and manage other common comorbidities:

  • Atrial fibrillation (check for irregular rhythm)
  • Diabetes (optimize glycemic control)
  • Coronary artery disease (consider non-invasive testing)
  • Sleep apnea (screen with sleep study if clinically indicated) 1

Monitoring and Follow-up

• Regular clinical assessment for symptoms and signs of congestion 1
• Echocardiographic follow-up to assess response to therapy 1
• Natriuretic peptide levels to monitor disease activity 1
• Consider pulmonary artery pressure monitoring in patients with recurrent hospitalizations 1

Important Caveats

• Rule out HFpEF mimics before finalizing diagnosis:

  • Infiltrative cardiomyopathies (especially cardiac amyloidosis)
  • Hypertrophic cardiomyopathy
  • Valvular heart disease
  • Pericardial disease 1

• Avoid medications that may worsen HFpEF:

  • Non-dihydropyridine calcium channel blockers
  • Thiazolidinediones
  • NSAIDs 1

• Beta-blockers should only be used if there are specific indications:

  • Prior myocardial infarction
  • Angina
  • Atrial fibrillation requiring rate control 1