Case: 74-year-old woman with HTN, obesity (BMI 46 kg/m2) with dyspnea, leg edema, ⬆️JVP, BNP = 28 pg/ml, LVEF 60%. What is the cause of HFpEF and abnormal septal motion?
Invasive hemodynamics: RA 18, PA 44/20 (mean 28), PCWP 20, CO 5.1 L/min. 
Answer: Obesity HFpEF phenotype with severe pericardial, epicardial fat over the RV causing pericardial constraint (not constrictive pericarditis--pericardium was normal). See: ahajournals.org/doi/10.1161/CI…
How would you treat this patient?
No single right answer here. Diet/exercise and SGLT2i could help, but I think pts like this need profound weight loss to make a difference. Bariatric surgery can do it. Pericardiotomy has been described in HFpEF and may help. GLP1-RAs = ⬇️⬇️ weight and may be helpful here.
Here's an example in one of my other patients with HFpEF, NYHA class III symptoms, and BMI 39.5 kg/m2. GLP1-RA resulted in dramatic weight loss and resolution of fluid overload and HTN and symptoms.
References for pericardiotomy in HFpEF: ncbi.nlm.nih.gov/pmc/articles/P…
ncbi.nlm.nih.gov/pmc/articles/P…
ncbi.nlm.nih.gov/pmc/articles/P…
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