What is the recommended treatment approach for a patient with normal left ventricular (LV) ejection fraction, grade II diastolic dysfunction, mild aortic valve stenosis, severely elevated pulmonary artery systolic pressure, and signs of right heart strain?

Management of Heart Failure with Normal Ejection Fraction, Diastolic Dysfunction, and Pulmonary Hypertension

Diuretics are the cornerstone of treatment for this patient with grade II diastolic dysfunction, normal LV ejection fraction, mild aortic stenosis, and severely elevated pulmonary artery pressure showing signs of right heart strain. 1, 2

Initial Assessment and Management

• The echocardiogram findings indicate heart failure with preserved ejection fraction (HFpEF) with grade II diastolic dysfunction and secondary pulmonary hypertension 1
• The dilated inferior vena cava with reduced respiratory variation confirms elevated right atrial pressure, suggesting right heart strain secondary to pulmonary hypertension 1
• Continuous monitoring of heart rate, rhythm, blood pressure, and oxygen saturation is recommended for at least the first 24 hours of admission 2
• Maintain oxygen saturation above 90% at all times to prevent worsening of pulmonary hypertension 2

Pharmacological Management

First-Line Therapy

• Loop diuretics (e.g., furosemide) are essential for symptomatic treatment of fluid overload as evidenced by the dilated IVC 1, 2
• Start with a low dose and titrate based on clinical response; consider doubling the dose if initial response is inadequate 2
• ACE inhibitors are recommended as first-line therapy even with preserved ejection fraction when there is evidence of pulmonary hypertension 1

Additional Therapies

• Consider adding a mineralocorticoid receptor antagonist (spironolactone) for patients with HFpEF and pulmonary hypertension 1
• Beta-blockers should be used cautiously and at low doses initially, as they may worsen pulmonary hypertension in some patients 1
• For patients with severe pulmonary hypertension, consider pulmonary vasodilators such as sildenafil (20 mg three times daily) 2

Management of Aortic Stenosis Component

• Mild aortic stenosis generally does not require specific intervention but should be monitored with echocardiography every 2 years 1
• If symptoms attributable to aortic stenosis develop or if there is progression to moderate or severe stenosis, more frequent monitoring (every 6-12 months) is recommended 1

Management of Pulmonary Hypertension

• Severely elevated pulmonary artery pressure in the setting of HFpEF requires aggressive management of left heart filling pressures through diuresis 1, 2
• Consider referral to a pulmonary hypertension specialist for patients with "disproportionate" pulmonary hypertension (higher than expected based on left heart pressures) 1
• Avoid excessive fluid administration as this may worsen right ventricular distention and compromise left ventricular filling 2

Monitoring and Follow-up

• Patients with HFpEF and pulmonary hypertension should be seen every 3 months initially 1
• Regular assessment of functional capacity through 6-minute walk tests or graded treadmill tests is recommended at each visit 1
• Consider hemodynamic monitoring with a pulmonary artery catheter in patients who are refractory to initial therapy 2
• For patients with severe pulmonary hypertension, wireless pulmonary artery pressure monitoring may guide management to reduce decompensation 3

Special Considerations

• Avoid medications that can worsen diastolic dysfunction such as non-steroidal anti-inflammatory drugs 1
• In contrast to systolic heart failure, calcium channel blockers may be beneficial in diastolic dysfunction to improve ventricular relaxation 4
• Atrial fibrillation should be aggressively managed as it can worsen diastolic dysfunction and pulmonary hypertension 1

Prognosis and Long-term Management

• The presence of diastolic dysfunction with pulmonary hypertension is associated with worse outcomes compared to isolated diastolic dysfunction 5
• Regular follow-up echocardiography is recommended to monitor progression of diastolic dysfunction, aortic stenosis, and pulmonary hypertension 1
• Patient education regarding fluid restriction, salt restriction, and daily weight monitoring is essential 1