Heart Failure With Preserved Ejection Fraction

Symptomatic heart failure, despite preserved left ventricular (LV) ejection fraction, is a well-recognized phenomenon. This manifestation of diastolic dysfunction is associated with increased morbidity and mortality and can be attributed to a variety of pathogeneses, including diabetes mellitus, hypertension, infiltrative processes, and obesity.1–5 Unlike in systolic heart failure, where LV ejection fraction readily stratifies disease severity, accurate diagnosis and grading of heart failure with preserved ejection fraction (HFpEF) can be a challenging. Without an equivalent, single, noninvasive diagnostic tool in HFpEF, we must instead rely on a myriad of measures to establish diagnosis and severity. This is best illustrated by the current European and American guidelines, which incorporate ≤8 separate imaging indices into their recommended protocols for diagnosis and classification of diastolic dysfunction.6,7 Although, new guidelines from the American Society of Echocardiography and the European Association of Cardiovascular Imaging will attempt to simplify assessment of diastolic dysfunction with the use of 4 key variables, such as mitral annular early diastolic (e′) velocities, average E/e′ ratio, indexed left atrial (LA) volume, and peak tricuspid regurgitant velocity (personal communication, A.L. Klein, MD, unpublished data, 2016).See Article by Freed et al LA size, initially measured as area and now revised to indexed volume, has long been felt to be a sentinel marker of diastolic dysfunction. As such, it features prominently in diagnostic algorithms and is measured routinely in all accredited echocardiographic laboratories. Increasing LA size typically reflects worsening diastolic dysfunction and is known to be associated with increased adverse events, including hospitalizations for heart failure and cardiac death.8 It is widely accepted that this increase in LA size is a consequence of chronically increased LV pressures, associated with increased myocardial stiffness and resultant impaired LV myocardial diastolic relaxation. Once dilated, LA volume will reduce but …