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Research Article | Volume 15 Issue 1 (Jan - Feb, 2025) | Pages 339 - 344
Exploring the Clinical Spectrum of Heart Failure with Preserved Ejection Fraction
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1
Post Graduate Student, Department of General Medicine, Shri Shankaracharya Institute of Medical Sciences, Bhilai, C.G.
2
Professor, Department of General Medicine, Shri Shankaracharya Institute of Medical Sciences, Bhilai, C.G.
3
Professor & HOD, Department of General Medicine, Shri Shankaracharya Institute of Medical Sciences, Bhilai, C.G.
4
Associate Professor, Department of General Medicine, Shri Shankaracharya Institute of Medical Sciences, Bhilai, C.G
5
Associate Professor, Department of General Medicine, Shri Shankaracharya Institute of Medical Sciences, Bhilai, C.G.
6
Assistant Professor, Department of General Medicine, Shri Shankaracharya Institute of Medical Sciences, Bhilai, C.G.
Under a Creative Commons license
Open Access
Received
Nov. 29, 2024
Revised
Dec. 8, 2024
Accepted
Dec. 30, 2024
Published
Jan. 28, 2025
Abstract

Background: Heart Failure with Preserved Ejection Fraction (HFpEF) poses a significant clinical challenge due to its complex pathophysiology and increasing prevalence, particularly among older adults. Despite normal or near-normal left ventricular ejection fraction, patients exhibit heart failure symptoms such as dyspnea and fatigue. HFpEF is commonly associated with comorbidities like hypertension, diabetes, and obesity, which complicate management and contribute to poor prognosis. Methods: A descriptive observational study was conducted over two years at a tertiary care hospital in Chhattisgarh. The study included 100 adult patients diagnosed with HFpEF, defined by symptoms of heart failure, left ventricular ejection fraction (LVEF) ≥ 50%, and without evidence of structural or cardiovascular heart disease. Clinical evaluation, laboratory tests, and imaging studies, including echocardiography, were performed to assess cardiac function. Statistical analysis was conducted using descriptive statistics, t-tests, and chi-square tests. Results: The study participants had a mean age of 56.72 years, with a balanced gender distribution. Fatigue (87%) and dyspnoea (82%) were the most common symptoms. Hypertension (88%) and diabetes (67%) were prevalent comorbidities. The mean ejection fraction was 54.53%, with mild diastolic dysfunction observed in 78% of patients. Conclusion: HFpEF primarily affects older adults with significant comorbidities, notably hypertension and diabetes. Although ejection fraction remains normal, mild diastolic dysfunction is common. These findings emphasize the need for comprehensive management strategies focusing on symptom relief and comorbidity control to improve patient outcomes.

Keywords
INTRODUCTION

Heart Failure with Preserved Ejection Fraction (HFpEF) represents a significant clinical challenge due to its complex pathophysiology and rising prevalence, especially among older adults [1,2]. Unlike Heart Failure with Reduced Ejection Fraction (HFrEF), where therapies have been more clearly defined, HFpEF lacks robust evidence-based treatment guidelines, contributing to high morbidity and mortality rates in affected individuals [3,4].

 

HFpEF is characterized by normal or near-normal left ventricular ejection fraction, alongside symptoms of heart failure such as dyspnea, fatigue, and exercise intolerance [5]. The condition is closely associated with a cluster of comorbidities, including hypertension, obesity, diabetes, and chronic kidney disease, which complicates its management and worsens the prognosis [6,7]. Emerging evidence suggests that the interplay between these comorbidities and cardiac structural changes, such as left ventricular hypertrophy and fibrosis, plays a pivotal role in the development and progression of HFpEF [8].

 

Recent studies have also highlighted the role of systemic inflammation, endothelial dysfunction, and altered myocardial metabolism in the pathogenesis of HFpEF [9]. Furthermore, the diagnostic process is often challenging due to the overlap of symptoms with other cardiac and pulmonary conditions, leading to underdiagnosis or delayed diagnosis  [10,11].

 

Understanding the clinical spectrum of HFpEF, including its associated risk factors, comorbidities, and hemodynamic changes, is essential for developing targeted therapeutic strategies and improving patient outcomes [12]. This study aims to explore the clinical profile of patients with HFpEF, providing insights into the demographic and clinical characteristics that define this population and highlighting the need for personalized management approaches.

MATERIALS AND METHODS

Study Design and Setting: 

This descriptive observational study was conducted over two years, from 2022 to 2024 in the Department of General Medicine at a tertiary care hospital in Chhattisgarh. The study aimed to investigate the clinical profile of patients with heart failure with preserved ejection fraction (HFpEF) and was approved by the Institutional Ethics Committee.

 

Study Population: 

The study included adult patients diagnosed with HFpEF, characterized by symptoms of heart failure, a preserved left ventricular ejection fraction (LVEF ≥50%), and evidence of structural heart disease or diastolic dysfunction on echocardiography. Inclusion criteria were age ≥18 years, both sexes, symptoms and signs of heart failure, and LVEF  ≥ 50%. Exclusion criteria were patients with LVEF <50%, history of cardiac surgeries, chest wall injuries, age <18 years, diuretic use, or refusal to consent.

 

Sample Size: 

The sample size was calculated using a formula based on the estimated prevalence of HFpEF, type 1 error (α=0.05), and allowable error (ε=0.1), resulting in a required sample size of 100 patients.

 

Patient Recruitment: 

Patients meeting the inclusion criteria were recruited after obtaining informed consent. A detailed medical history, including cardiovascular events, comorbidities, lifestyle factors, and family history, was recorded.

 

Clinical Examination: 

Each patient underwent a thorough clinical evaluation, including assessment of symptoms like dyspnea, fatigue, and peripheral edema. Physical examinations included vital signs, cardiac and peripheral examinations for signs such as edema, jugular venous distention, and abnormal heart sounds.

 

Laboratory and Imaging Studies: 

Laboratory tests included complete blood count, serum electrolytes, renal and liver function tests, fasting blood glucose, HbA1c, lipid profile, and cardiac biomarkers like BNP/NT-proBNP and troponin levels. Imaging studies involved 2D echocardiography to assess cardiac structure and function, chest X-ray for heart size and pulmonary congestion, and a 12-lead ECG to detect arrhythmias, ischemic changes, and left ventricular hypertrophy.

 

Statistical Analysis: 

Data were analyzed using descriptive statistics to summarize demographic and clinical characteristics. Continuous variables were reported as means or medians, and categorical variables as frequencies or percentages. T-tests, chi-square tests, and multivariable regression analyses were employed to identify significant associations, with p < 0.05 considered statistically significant.

RESULTS

The distribution shows that most males are aged 50-60, while most females are aged 60-70. Males are more common in younger age groups, and females in older ones. Overall, the gender distribution is nearly equal, with 52 males and 48 females (Figure 1).

 

The age of patients ranges from 21 to 88 years, with a mean age of 56.72 years and a standard deviation of 13.51 years. This indicates that while most patients are concentrated around the average age, there is a considerable variation in age within the study population (Figure 2).

 

Table1: Clinical Presentation

 

Symptom

Numberof patients

Frequency

Percentage

Fatigue

87

87

Dyspnea

82

82

  Edema

61

61

Paroxysmal nocturnal dyspnoea

52

52

 

The most common symptoms among patients were fatigue (87%) and dyspnoea (82%). Edema and paroxysmal nocturnal dyspnoea were less frequent but still notable, affecting 61% and 52% of patients, respectively (Table 1).

 

Table 2: Distribution of comorbidity

Comorbidity

Frequency

Percentage

Hypertension

88

88

Diabetes

67

67

 

Hypertension is the most prevalent comorbidity, affecting 88% of patients, while 67% have diabetes. These findings highlight the significant presence of these conditions among the study population (Table 2).

 

Dyslipidaemia was present in 58% of patients, while 42% did not have the condition. This indicates a moderate prevalence of dyslipidaemia within the study population (Table 3).

 

Table 3: Parameters of Cardiac Function

Parameters

Mean

Standard Deviation

EF (Ejection Fraction)

54.53

3.77

E (Early diastolic mitral inflow velocity)

0.652

0.24

A (Late diastolic mitral inflow velocity)

0.847

0.13

E/A Ratio

0.741

0.21

DT

169.19

15.24

 

The mean ejection fraction (EF) is 54.53% with a standard deviation of 3.77, indicating a relatively stable measure of heart function. The early diastolic mitral inflow velocity (E) averages 0.652 with a standard deviation of 0.24, while the late diastolic mitral inflow velocity (A) is 0.847 with a standard deviation of 0.13. The E/A ratio has a mean of 0.741 and a standard deviation of 0.21. Deceleration Time (DT) averages 169.19 Ms with a standard deviation of 15.24, reflecting variability in diastolic filling (Table 3).

 

Table4: Overall diastolic function status (GRADE)

GRADE

Frequency

Percentage

GRADE1

78

78

GRADE2

22

22

GRADE3

0

0

 

The majority of patients have diastolic function classified as GRADE 1 (78%), indicating a predominantly normal or mildly impaired diastolic function. A smaller proportion is classified as GRADE 2 (22%), reflecting moderate impairment. No patients fall into GRADE 3, suggesting severe diastolic dysfunction is absent in this population (Table 4).

DISCUSSION

Our study explored the clinical spectrum of Heart Failure with Preserved Ejection Fraction (HFpEF), providing valuable insights into the demographic characteristics, symptomatology, comorbidities, and functional parameters associated with this condition.

 

Age and Gender Distribution:

The age distribution of patients in our study (Figure 1) shows that HFpEF predominantly affects older adults, with a mean age of 56.72 years and a range from 21 to 88 years (Figure 2). This is consistent with the literature, which suggests that HFpEF is more common in older populations due to age-related changes in cardiac structure and function [13,14]. The gender distribution indicates a relatively balanced representation between males and females, although a slight female predominance in the older age groups was observed, aligning with other studies that have noted a higher prevalence of HFpEF in women [15,16].

 

Clinical Presentation:

The symptom profile in our study reveals that dyspnoea and fatigue are the most prevalent symptoms, affecting 82% and 87% of patients, respectively (Table 1). These findings are consistent with the typical presentation of HFpEF, where exertional dyspnoea and fatigue are common due to impaired cardiac filling and increased left atrial pressures [17,18]. The presence of paroxysmal nocturnal dyspnoea and edema in 52% and 61% of patients highlights the variability in symptom presentation, which can influence diagnosis and management strategies [19].

 

Comorbidities:

Hypertension and diabetic mellitus were identified as prevalent comorbidities, affecting 88% and 67% of patients, respectively (Table 2). This high prevalence is consistent with existing research, which emphasizes the strong association between these conditions and the development of HFpEF [20, 21]. The management of HFpEF often involves addressing these comorbidities to improve overall patient outcomes.

 

Dyslipidaemia:

Dyslipidaemia was present in 58% of patients (Figure3), indicating a notable but not overwhelming prevalence. This aligns with other studies that have found dyslipidaemia to be a common but less predominant factor compared to hypertension and diabetes in HFpEF patients [22, 23].

 

Cardiac Function Parameters:

The cardiac function parameters measured in our study show a mean ejection fraction of 54.53% (Table 3), consistent with the definition of HFpEF where ejection fraction is typically preserved. The other parameters, such as early and late diastolic mitral inflow velocities, E/A ratio, and deceleration time, provide insight into the diastolic function, which is often impaired in HFpEF despite a normal ejection fraction [24,25]. The E/A ratio of 0.741 and a deceleration time of 169.19 ms reflect a pattern of impaired relaxation and increased filling pressures, common in HFpEF [26,27].

 

Diastolic Function Status:

Our grading of diastolic function (Table 4) reveals that most patients are classified as GRADE 1, indicating mild diastolic dysfunction. This is consistent with findings that diastolic dysfunction in HFpEF is often mild to moderate [28, 29]. The absence of patients in GRADE 3 highlights that severe diastolic dysfunction is less common in our study population.

 

Overall, our findings align with the current understanding of HFpEF and underscore the importance of a comprehensive evaluation, including symptom assessment, comorbidity management, and detailed cardiac function analysis.

CONCLUSION

Our study on Heart Failure with Preserved Ejection Fraction (HFpEF) highlights that it primarily affects older adults, with common symptoms including dyspnoea and fatigue. Hypertension and diabetes are prevalent comorbidities. Although ejection fraction remains normal, diastolic function is often impaired, with most patients showing mild dysfunction. Dyslipidaemia is common but less so than hypertension and diabetes. These findings emphasize the need for comprehensive management of symptoms and comorbidities, and further research is needed to enhance treatment strategies.

 

Limitation:

This study has several limitations that should be considered. First, the study's observational design restricts the ability to establish causal relationships between HFpEF and its associated factors. Second, the single-center nature of the study may limit the generalizability of the findings to other populations or healthcare settings. Third, the reliance on clinical and echocardiographic parameters may not capture all aspects of diastolic dysfunction or underlying pathology. Lastly, the sample size, while sufficient for descriptive analysis, may not be large enough to detect fewer common associations or effects. Future studies with larger, multicentric designs and more comprehensive diagnostic tools are needed to validate and expand upon these findings.

 

Conflict of Interest:

The authors declare no conflicts of interest related to this study. All research was conducted independently and without external influence.

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