Heart Failure with Preserved Ejection Fraction: Current Management and Future Strategies
Hypertension (HTN) represents the most important attributable risk factor for heart failure (HF). The measurement of left ventricular (LV) ejection fraction (EF) is the basis for the description of HF in different patients, from those with normal EF (abov
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Enrico Agabiti Rosei and Damiano Rizzoni
Hypertension (HTN) represents the most important attributable risk factor for heart failure (HF). The measurement of left ventricular (LV) ejection fraction (EF) is the basis for the description of HF in different patients, from those with normal EF (above 50% HF with preserved EF (HFpEF)) to those with reduced EF (below 40%, HF with reduced EF (HFrEF)) [1]. Recent ESC guidelines have identified patients with an LVEF in the range 40–49%, defined as HFmrEF, which in different studies have been considered in the group with HFpEF [2]. HFpEF accounts for about 50% of HF cases, but its prevalence relative to HFrEF continues to rise. HFpEF carries similar risk of morbidity/mortality as HFrEF. Patients with HFpEF are frequently old women with HTN, usually also with diabetes and obesity, characterized by concentric LV hypertrophy (LVH), increased left atrial (LA) size, diastolic dysfunction, pulmonary hypertension, and elevated levels of natriuretic peptides.
21.1 Hypertension and HFpEF The development of LVH in HTN is a strong predictor of HF, even when LV systolic function is normal and no evidence of ischemic heart disease is present, thus representing a leading risk factor for HFpEF [1, 3, 4]. It is believed that diastolic abnormalities may precede systolic chamber dysfunction, despite this aspect needs further clarification with longitudinal studies. HFpEF and HFrEF share similar symptoms, signs, and some pathophysiological features, such as endothelial dysfunction and neurohormonal imbalance. However, some evidences suggest that these two forms of HF may represent two distinct diseases, with different timings and different changes in myocardial structure and function. In fact, the development E. A. Rosei (*) · D. Rizzoni Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy e-mail: [email protected]; [email protected] © Springer Nature Switzerland AG 2019 M. Dorobantu et al. (eds.), Hypertension and Heart Failure, Updates in Hypertension and Cardiovascular Protection, https://doi.org/10.1007/978-3-319-93320-7_21
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E. A. Rosei and D. Rizzoni
of HFpEF in patients with LVH is usually associated with a progressive change in the extracellular matrix and an increase in perivascular and interstitial fibrosis. The presence of inappropriate LV mass, i.e., an increase in LV mass that exceeds the amount appropriate for individual cardiac workload, sex, and body size, is probably related to cardiovascular structural and functional abnormalities, which lead to cardiovascular events, in particular to the development of HF (Fig. 21.1). The incidence of HF is reduced with antihypertensive treatment able to correct LV mass inappropriateness. Patients with HFpEF may have coronary microvascular rarefaction and also dysfunction, possibly as a consequence of a systemic inflammatory status and oxidative stress, accelerated by comorbidities which are frequent in this condition. Patients with HFpEF often present incre
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