HFpEF

Disease:

Definition	· What it says it is!
Significance	· Common · Increased periop mortality and morbidity · No effective treatment
Aetiology	· ↓Relaxation o Old age o Ischaemia · ↓Compliance o Ventricle (e.g. aortic stenosis, infiltration) o Pericardium · ↓Venous return o Right heart failure o Inflow obstruction · Congenital
Risk factors	· Old age o Most have diastolic impairment o Diagnosis of HFpEF requires symptoms · Usual suspects o Obesity o IHD o PHTN o AF o T2DM o HTN

Criteria

· ACC/AHA: symptoms + normal EF

· ES: symptoms + normal EF + diastolic impairment + ↑BNP

Echo

Diagnostic:

· Abnormal E/A

· ↑E/e’ ratio

Suggestive:

· Big atrium

· Ventricular hypertrophy

· Thick pericardium

Invasive

· ↑PCWP >15 = ↑LVEDP >16
(With normal ejection fraction)

Severity	E/A	e’	E/e’	Significance
Normal	1-2	>10
1.Impaired filling	<1	<10	<9	Greater reliance on sinus rhythm Fluid bolus good
2.Pseudonormal	1-2	<10	9-12	Passive > atrial kick at expense of congestion Fluid bolus bad
3.Restrictive	>2	<10	>12	Ventricle very stiff Fluid bolus very bad

*Note E/A requires sinus rhythm.

General	· Nothing, really · ACE inhibitor, beta blocker, diuretics probably good · Preserve sinus rhythm · Control heart rate · Treat hypertension · Treat T2DM · Treat IHD
Fluids	· Rock: high filling pressures are required for cardiac output · Hard place: also at risk of pulmonary oedema · Fluid bolus only helpful if mild impairment
Intra-op	‘Rule of 70s’ · If age >70 then assume it is there · HR 70 · DBP >70 · PP <70 Principles: · Sympatholysis (i.e. opioids, neuraxial, regional, local) · Optimise preload (beware volume status, beware positioning)
Post-op	· Monitor in HDU – risk of AF, APO, AMI · Sympatholysis (as above) · Optimise preload (as above)