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

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

 

Diagnosis:

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)

 

Echo:

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.

 

Management:

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)

 

 

Feedback welcome at ketaminenightmares@gmail.com