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Heart Failure with Preserved LVEF

Heart Failure with Preserved LVEF. HFSA 2010 Recommendations. HFSA 2010 Practice Guideline Preserved LVEF—Diagnosis. Recommendation 11.1

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Heart Failure with Preserved LVEF

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  1. Heart Failure with Preserved LVEF HFSA 2010 Recommendations

  2. HFSA 2010 Practice GuidelinePreserved LVEF—Diagnosis • Recommendation 11.1 • Careful attention to differential diagnosis is recommended in patients with HF and preserved LVEF to distinguish among a variety of cardiac disorders, because treatments may differ. • These various entities may be distinguished based on: • Echocardiography • Electrocardiography • Stress imaging (via exercise or pharmacologic means, using myocardial perfusion or echocardiographic imaging). • Cardiac catheterization Strength of Evidence = C

  3. Figure 11.1. Diagnostic Criteria:HF with Reduced vs. HF with Preserved EF Clinical evidence of HF: Clear clinical presentation of HF or Framingham or Boston criteria If uncertain: Plasma BNP or chest x-ray or cardiopulmonary exercise testing LVEF < 50% LVEF ≥ 50% Supportive evidence: Concentric LVH or remodeling Left atrial enlargement in absence of AF Echo Doppler or catheter evidence of diastolic dysfunction Supportive evidence: Eccentric LVH or remodeling Exclusions: Non-myocardial disease Exclusions: Non-myocardial disease Adapted from Yturralde FR. Prog Cardiovasc Dis 2005;47:314-19

  4. Figure 11.2. Etiology of HF with Reduced vs. HF with Preserved LVEF HF with Reduced EF HF with Preserved EF Myocardialb Myocardialb Non-Myocardiala Non-Myocardiala Hypertension Hypertension CAD CAD Valvular disease AS, AR, MR, MS Diabetes Diabetes Valvular disease AS, AR, MR, MS Cardiomyopathy genetic,post-partum, viral, drug/radiation Cardiomyopathy genetic, post-partum, viral, drug/radiation Pericardial constraint constriction, tamponade High output Anemia, AV fistula Infiltrative myopathyc Infiltrative myopathyc High output Anemia, AV fistula a = cause of HF or specific target for therapy b = disease process that may lead to HF c = may have stage in which EF is normal, but often declines

  5. Figure 11.3. Diagnostic Algorithmfor HF with Preserved LVEF No inducible ischemia, fibrotic, collagen- Vascular, RCM, cardinoid, diabetes, Radiation or chemotherapy induced heart disease, infiltrative disease, co- morbid conditions, reconsider diagnosis of HF

  6. HFSA 2010 Practice GuidelinePreserved LVEF—Evaluation • Recommendation 11.2 • Evaluation for ischemic heart disease and inducible myocardial ischemia is recommended in patients with HF and preserved LVEF. • Strength of Evidence = C

  7. HFSA 2010 Practice GuidelinePreserved LVEF—Blood Pressure • Recommendation 11.3 • Blood pressure monitoring is recommended in patients with HF and preserved LVEF. • Strength of Evidence = C

  8. HFSA 2010 Practice GuidelinePreserved LVEF—Low Sodium Diet • Recommendation 11.4 • Counseling on the use of a low sodium diet is recommended for all patients with HF, including those with preserved LVEF. • Strength of Evidence = C

  9. HFSA 2010 Practice GuidelinePreserved LVEF—Diuretics • Recommendation 11.5 • Diuretic treatment is recommended in all patients with HF and volume overload, including those with preserved LVEF. • Treatment may begin with either a thiazide or loop diuretic. • In more severe volume overload or if response to a thiazide is inadequate, treatment with a loop diuretic should be implemented. • Avoid excessive diuresis, which may lead to orthostatic changes in blood pressure and worsening renal function. Strength of Evidence = C

  10. HFSA 2010 Practice GuidelinePreserved LVEF—ARBs or ACEIs • Recommendation 11.6 • In the absence of other indications for these drugs, ARBs or ACE inhibitors may be considered in patients with HF and preserved LVEF: • ARBs Strength of Evidence = C • ACE inhibitors Strength of Evidence = C

  11. HFSA 2010 Practice GuidelinePreserved LVEF—ACE Inhibitors • Recommendation 11.7 • ACE inhibitors should be considered in all patients with HF and preserved LVEF who have: • symptomatic atherosclerotic cardiovascular disease • or diabetes and one additional risk factor Strength of Evidence = C • In patients who meet these criteria but are intolerant to ACE inhibitors, ARBs should be considered. Strength of Evidence = C

  12. HFSA 2010 Practice GuidelinePreserved LVEF—Beta Blockers • Recommendation 11.8 • Beta blocker treatment is recommended in patients with HF and preserved LVEF who have: • Prior MI Strength of Evidence = A • Hypertension Strength of Evidence = B • Atrial fibrillation requiring control of ventricular rate Strength of Evidence = B

  13. HFSA 2010 Practice GuidelinePreserved LVEF—CCBs • Recommendation 11.9 • Calcium channel blockers should be considered in patients with HF and preserved LVEF and: • Atrial fibrillation requiring control of ventricular rate and intolerance to beta blockers. In these patients, diltiazem or verapamil should be considered. Strength of Evidence = C • Symptom-limiting angina. Strength of Evidence = A • Hypertension. Strength of Evidence = C

  14. HFSA 2010 Practice GuidelinePreserved LVEF—Symptomatic AF • Recommendation 11.10 • Measures to restore and maintain sinus rhythm may be considered in patients who have symptomatic atrial flutter-fibrillation and preserved LVEF, but this decision should be individualized. • Strength of Evidence = C

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