Critical Care Medicine-Neurologic Disorders>>>>>Heart Failure
Question 2#

An 81-year-old woman with a body mass index of 36 kg/m2 and longstanding congestive heart failure, hypertension, atrial fibrillation, and chronic obstructive pulmonary disease is admitted to the intensive care unit with exacerbation of heart failure. The patient presented with severe shortness of breath, diffuse bilateral pulmonary edema on chest x-ray, elevated brain natriuretic peptide levels of 13 187 pg/mL, and an elevated creatinine of 2.13 mg/dL. Echocardiogram reveals a left ventricular ejection fraction of 55%.

Which statement with regards to this patient is most accurate?

a. Beta-blocker therapy yields equal reduction in mortality in diastolic heart failure versus systolic heart failure patients
b. Ischemic heart disease is the major mechanism leading to diastolic heart failure
c. Diastolic heart failure is characterized by eccentric ventricular hypertrophy
d. Diastolic pulmonary gradient is a poor predictor of mortality in patients with pulmonary hypertension due to left heart disease
e. Patients with diastolic heart failure have a lower 5-year survival than patients with systolic heart failure

Correct Answer is D

Comment:

Correct Answer: D

Although obesity, coronary artery disease, diabetes mellitus, atrial fibrillation, and hyperlipidemia are highly prevalent in patients with HFpEF, hypertension is the most important cause of HFpEF. It is associated with concentric ventricular hypertrophy and increased ventricular mass. The prevalence of HFpEF has increased over a study period of 15 years, whereas survival remained unchanged during the interval. Survival of patients with HFpEF has been reported to be higher or similar to that of patients with reduced ejection fraction. While beta-blocker, diuretics, and ACE-inhibitors are frequently used in patients with HFpEF; results from randomized controlled trials evaluating these regimens in patients with HFpEF have been disappointing. Several beta-blockers proved to be effective in reducing the risk of death in patients with chronic heart failure with reduced ejection fraction (HFrEF). According to the 2013 ACC/AHA guidelines on heart failure management, the randomized controlled trials mostly enrolled patients with HFrEF, and it is only in these patients that efficacious therapies have been demonstrated; ie, no efficacious therapies for HFpEF patients have been identified to date. In a retrospective study of 1236 patients with cardiomyopathy and pulmonary hypertension due to left heart disease, an elevated diastolic pulmonary gradient was not associated with worse survival. Other studies also confirmed that diastolic pulmonary gradient is a poor predictor of mortality in patients with pulmonary hypertension due to left heart disease.

References:

  1. Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure: part II: causal mechanisms and treatment. Circulation. 2002;105:1503-1508.
  2. Zile MR, Brutsaert DL. New concepts in diastolic dysfunction and diastolic heart failure: part I: diagnosis, prognosis, and measurements of diastolic function. Circulation. 2002;105:1387-1393.
  3. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147-e239.
  4. Tampakakis E, Leary PJ, Selby VN, et al. The diastolic pulmonary gradient does not predict survival in patients with pulmonary hypertension due to left heart disease. JACC Heart Fail. 2015;3:9-16.