Chronic Heart Failure with Preserved Ejection Fraction in A Comorbid Patient: Issues in Verification of A «Difficult» Diagnosis

Chronic heart failure with preserved ejection fraction (HFpEF) is a complex, heterogeneous, multi-organ systemic syndrome characterized by significant morbidity and mortality. Currently, it has acquired the character of an epidemic of the 21st century. The clinical observation describes a typical story of an elderly patient suffering from coronary artery disease (CAD), dyslipidemia, atherosclerosis of the brachiocephalic arteries against the background of arterial hypertension (AH), obesity, type 2 diabetes mellitus (DM), complicated by diabetic retinopathy, polyneuropathy, nephropathy with development of chronic kidney disease (CKD) and HFpEF. The condition was aggravated by the presence of chronic pyelonephritis of a single kidney (right nephrectomy for renal abscess in 2013), bronchial asthma. The limitations of modern scales for determining the pre-test probability of HFpEF and low natriuretic peptide levels are demonstrated. Comorbidity, poorly controlled hypertension, diabetes, low adherence to therapy led to the development of acute vascular accident, then, repeated cerebrovascular accident — to a fatal outcome. Histologically, perivascular and interstitial sclerosis in the myocardium and epicardium was detected, which is the basis of diastolic dysfunction in HFpEF.
A clinical example reflects the difficulties of verification of HFpEF-diagnosis, as well as the mutual pathogenetic influence of concomitant pathology, which can lead to an unfavorable outcome if recommendations are not followed.

1. Hamo CE, DeJong C, Hartshorne-Evans N. et al. Heart failure with preserved ejection fraction. Nat Rev Dis Primers. 2024;10( 1):55. doi: 10.1038/s41572-024-00540-y.

2. Cohen JB, Schrauben SJ, Zhao L, et al. Clinical Phenogroups in Heart Failure With Preserved Ejection Fraction: Detailed Phenotypes, Prognosis, and Response to Spironolactone. JACC Heart Fail. 2020;8(3):172-184. doi: 10.1016/j.jchf.2019.09.009.

3. Nizov AA, Suchkova EI, Girivenko AI, et al. Possibilities of use of metformin for correction of endothelial dysfunction and adaptation reserves of an organism in patients with metabolic syndrome. I.P. Pavlov Russian Medical Biological Herald. 2019;27(4):458-467. doi: 10.23888/PAVLOVJ2019274458-467. [in Russian]

4. Galjavich A.S., Tereshhenko S.N., Uskach T.M. i dr. Klinicheskie rekomenda cii “Hronicheskaja serdechnaja nedostatochnost’” Ministerstva zdravoohranenija Rossjiskoj Federacii. Rossijskoe kardiologicheskoe obshhestvo. 2024. [in Russian]

5. Lin Y, Fu S, Yao Y, et al. Heart failure with preserved ejection fraction based on aging and comorbidities. J Transl Med. 2021;19(1):291. doi: 10.1186/s12967-021-02935-x.

6. Stoicescu L, Crişan D, Morgovan C, et al. Heart Failure with P reserved Ejection Fraction: The Pathophysiological Mechanisms behind the Clinical Phenotypes and the Therapeutic Approach. Int J Mol Sci. 2024;25(2):794. doi: 10.3390/ijms25020794.

7. Ageev F.T., Yarovaya E.B., Ovchinnikov A.G. Рossibility of using European (HFA-PEFF) and American (H2FPEF) algorithms for diagnosing heart failure with preserved ejection fraction in Russian clinical practice. Kardiolog iia. 2022;62(12):4-10. doi: 10.18087/cardio.2022.12.n2280. [in Russian]

8. Ivanova A.A., Dzhioeva O.N., Lavrenova E.A., et al. Diagnostic challenges of heart failure with preserved ejection fraction: focus on echocardiography. Cardiovascular Therapy and Prevention. 2023;22(5):3565. doi: 10.15829/1728-8800-2023-3565. [in Russian]

9. Shah SJ. BNP: Biomarker Not Perfect in heart failure with preserved ejection fraction. Eur Heart J. 2022;43(20):1952-1954. doi: 10.1093/eurheartj/ehac121.

10. Clemen te G, Soldano JS, Tuttolomondo A. Heart Failure: Is There an Ideal Biomarker? Rev Cardiovasc Med. 2023;24(11):310. doi: 10.31083/j.rcm2411310.

11. Ha Manh T, Do Anh D, Le Viet T. Effect of body mass index on N-terminal pro-brain natriuretic peptide values in patients with heart failure. l. The Egyptian Heart Journal. 2023;75:75. doi: 10.1186/s43044-023-00401-1

12. Nikolaev K.Yu., Shilova A.V., Kovaleva A.Ya., et al. Role of brain natriuretic peptide in the pathogenesis of resistant hypertension. Russian Journal of Cardiology. 2023;28(1):5188. doi: 10.15829/1560-4071-2023-5188. [in Russian]

13. Bayes-Genis A, Docherty KF, Petrie MC, et al. Practical algorithms for early diagnosis of heart failure and heart stress using NTproBNP: A clinical consensus statement from the Heart Failure Association of the ESC. Eur J Heart Fail. 2023;25(11):1891-1898. doi: 10.1002/ejhf.3036.

14. Schiattarella GG, Rodolico D, Hill JA. Metabolic inflammation in heart failure with preserved ejection fraction. Cardiovasc Res. 2021;117(2):423-434. doi: 10.1093/cvr/cvaa217.

15. Paulus WJ, Zile MR. From Systemic Inflammation to Myocardial Fibrosis: The Heart Failure With Preserved Ejection Fraction Paradigm Revisited. Circ Res. 2021;128(10):1451-1467. doi: 10.1161/CIRCRESAHA.121.318159.

16. Stencel J, Alai HR, Dhore-Patil A, et al. Obesity, Preserved Ejection Fraction Heart Failure, and Left Ventricular Remodeling. J Clin Med. 2023;12(9):3341. doi: 10.3390/jcm12093341.

17. Ponomareva O.V., Smirnova E.A. Modern View on the Role of Myocardial Fibrosis and Its B iochemical Markers in Diagnosis of Chronic Heart Failure. Science of the young (Eruditio Juvenium). 2024;12(2):303– 316. doi: 10.23888/HMJ2024122303-316. [in Russian]

18. Davies MJ, Aroda VR, Collins BS, et al. Management of Hyperglycemia in Type 2 Diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2022;45(11):2753-2786. doi: 10.2337/dci22-0034.

19. Szlagor M, Dybiec J, Młynarska E, et al. Chronic Kidney Disease as a Comorbidity in Heart Failure. Int J Mol Sci. 2023;24(3):2988. doi: 10.3390/ijms24032988.

20. Drapkina OM, Kontsevaya AV, Kalinina AM, et al. Comorbidity of patients with noncommunicable diseases in general p ractice. Eurasian guidelines. Cardiovascular Therapy and Prevention. 2024;23(3):3996. doi: 10.15829/1728-8800-2024-3996

21. Kobalava ZhD, Konradi AO, Nedogoda SV, et al. 2024 Clinical practice guidelines for Hypertension in adults. Russian Journal of Cardi ology. 2024;29(9):6117. doi: 10.15829/1560-4071-2024-6117.