Skill Checkup: A Woman With Long‐standing Hypertension and Worsening Dyspnea on Exertion

Yasmine S. Ali, MD

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December 23, 2021

Symptoms of HF include breathlessness, cough, interrupted sleep, exercise intolerance, edema, and fatigue. These are the same for both HFpEF and HFrEF. The presence of these symptoms can confound the diagnosis of HF as they also occur in noncardiac conditions, including renal impairment and chronic obstructive pulmonary disease.

Conventional wisdom was that HF described a patient with an enlarged heart that is weak and unable to pump, but that definition started to change in the 1990s. The concept of preserved HF means that the heart is not necessarily enlarged: it squeezes the blood out of the heart well, but it is stiff. It does not relax adequately; it has reduced elasticity and reduced ability to expand to receive more blood. Patients with HFpEF generally do not have a dilated left ventricle, but instead often have an increase in LV wall thickness and/or increased left atrial size as a sign of increased filling pressures. Most have additional evidence of impaired LV filling or suction capacity, also classified as diastolic dysfunction, which is generally accepted as the likely cause of HF in these patients (hence the term diastolic HF). However, most patients with HFrEF (previously referred to as systolic HF) also have diastolic dysfunction, and subtle abnormalities of systolic function have been shown in patients with HFpEF.

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