Diagnosing Heart Failure with Preserved Ejection Fraction in Obese Patients

Figures

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  Figure 1. Challenges in evaluating left ventricular (LV) function and structure in the obese; (A) for better endocardial delineation IV contrast is used to measure LV ejection fraction accurately. (B) LV global longitudinal strain (GLS) is assessed to detect subtle endomyocardial LV dysfunction. (C) LV relative wall thickness and mass are estimated based on the LV wall thickness and end-diastolic diameter. In the case of this female obese patient, LV mass index (LVMI) calculated with body surface area (BSA) indexing falls into the normal category (61 g/m2 < 95 g/m2), while for another female of the same height, but with a normal body mass index (BMI) (height 162 cm, weight 49 kg, BMI = 18.7 kg/m2 and BSA = 1.48 m2), the LVMI (97 g/m2) along with the relative wall thickness (RWT) = 0.48 would indicate LV concentric hypertrophy. Abbreviations: LVEDD, left ventricular end-diastolic diameter; PW, posterior wall.

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  Figure 2. Algorithm for diastolic dysfunction assessment in patients who are obese with body mass index (ΒΜΙ) >30 kg/m2. After evaluating the blue boxes, follow the green in case of sinus rhythm (SR), the red for atrial fibrillation (AF), and the purple for pulmonary hypertension (PH). Abbreviations: E DT, mitral E wave deceleration time; DD, diastolic dysfunction; LAP, left atrial pressure; LArS, left atrium reservoir strain; LAVI, left atrium volume index to height; LV, left ventricular; Pulm S/D, pulmonary vein systolic/diastolic velocity ratio; TR Vmax, tricuspid regurgitation maximum velocity.

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  Figure 3. Improvement in accuracy of tricuspid regurgitation (TR) maximum velocity (Vmax) assessment with the use of intravenous contrast enhancing agent. The continuous wave Doppler evaluation of TR Vmax (A) without contrast is suboptimal. (B) TR Vmax with contrast is clearly detected.

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  Figure 4. Echocardiographic assessment of left ventricular diastolic dysfunction in an obese patient with atrial fibrillation. (A) E wave velocity is >1 but deceleration time (DT) is >160 ms. (B) E/e’ ratio at the interventricular septum (IVS) is >11. (C) Tricuspid regurgitation (TR) Vmax is <2.8 m/s. Two parameters are positive and two are negative according to the diastolic dysfunction algorithm. (D) Left atrial (LA) reservoir strain is <16%. Hence, since the patient is obese (body mass index > 30 kg/m2), the LV filling pressure is elevated.

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  Figure 5. Stepwise application of the two diagnostic algorithms for HFpEF diagnosis. The corresponding color denotes comparable steps between the two algorithms. Abbreviations: AF, atrial fibrillation; BMI, body mass index; H2FPEF, Heavy, Hypertension, Atrial Fibrillation, Pulmonary Hypertension, Elder, and Filling Pressures; HFA-PEFF, Heart Failure Association Pretest Probability of Heart Failure with Preserved Ejection Fraction; HFpEF, heart failure with preserved ejection fraction.