1/ How to use the H2FPEF score () to assist with the diagnosis of #HFpEF. ncbi.nlm.nih.gov/pmc/articles/P…
2/ First, H2FPEF score should only be used in pts w/dyspnea or exercise intolerance in whom the diagnosis of HFpEF vs non-cardiac dyspnea is unclear. If unsure about presence of symptoms: Do a 6MWT in the clinic to more objectively determine if exercise intolerance is present.

1/ #HFpEF treatment algorithm #tweetorial. This is the algorithm I currently use to treat HFpEF based on evidence we have thus far and my anecdotal experience treating patients over the past 16 years in the @NMCardioVasc HFpEF Clinic. 2/ This treatment algorithm was recently published in @JACCJournals with my friends and co-authors Barry Borlaug, @KSharmaMD, and @JenHoCardiology (who provided great feedback!). jacc.org/doi/abs/10.101…

1/ Grant-writing tips. This #tweetorial mainly applies to @NIH grants (particularly R01s) but some stuff may be applicable to other types of grants and funding agencies. Based on my experience writing grants for 20 yrs +lots of cringe-worthy missteps and rejections along the way! 2/ Where do you begin? Part 1: pick scientific topics that you love thinking about and reading about. Start building a story. Publish 4-5 papers on your topic (1st or last author) to establish yourself. Make sure you're senior author on a few papers (shows independence)

#HFpEF pearl of the day: Eval of filling pressures is critical for HFpEF management. Use entire echo and integrate info for filling pressures assessment: E, E/A, decel time, pulm vein flow, LA volume, LA strain, PASP, PR end-diastolic gradient, IVC, hepatic vein, tricuspid E/e'. ⬆️E, ⬇️DT, ⬆️E/A, and D-dominant pulm vein flow (in older pts); ⬆️E/e’, ⬆️LA volume (esp. ⬆️LA min volume), ⬇️LA reservoir strain; ⬆️PASP, ⬆️PREDP gradient (in absence of PAH); ⬆️tricuspid E/e’ > 6, ⬆️size ⬇️collapsibility of IVC, hep. vein flow reversal all = ⬆️filling pressures

#HFpEF pearl of the day: Once the Dx of HFpEF is made, the 1st step is looking for and Rx'ing congestion, then Rx'ing comorbidities, and then exercise/weight loss program. I use sequential nephron blockade to minimize loop diuretic dose, always try to use MRAs when possible.

#HFpEF pearl of the day: speckle-tracking strain bullseye map of the LV can help determine etiology of HFpEF. Here's an example: 58-year-old man with HTN, CKD presents with SOB, leg swelling, elevated JVP. Echo shows normal LVEF. What did his ECG show?

#HFpEF pearl of the day: Always look at echo LVOT VTI when eval. HFpEF pts. Normal 18-22 cm at HR 60-100. ⬆️LVOT VTI: look for NASH, anemia, cirrhosis, AVMs, etc. If ⬇️LVOT VTI: infiltrative/restrictive CM, constriction, LA failure, PAH, RV failure, obstructive lung dz, MS, etc. If ⬆️LVOT, measure volumes/dimensions of all 4 cardiac chambers to look for enlargement. Case: 31 yo woman previously healthy presents with dyspnea, leg swelling, BNP 166 pg/ml. Training for a marathon. Urine pregnancy test negative.

#HFpEF pearl of the day: In HFpEF pts with #CardioMEMS devices, bike stress echo + continuous CardioMEMS PA pressure recording can help evaluate underlying pathophysiologic abnormalities. Case: 71 yo woman w/apical HCM, AF s/p ablation, pacemaker, HTN, CKD with cardiorenal syndrome and PH-HFpEF presents with worsening overload. Echo shows preserved LVEF with apical HCM, PASP 85 mmHg, RAP 15 mmHg, RVOT PW notching consistent with ⬆️PVR.

#HFpEF pearl of the day: Bike stress echo is very helpful in the evaluation of HFpEF. In 1 test you can diagnose HFpEF (E/e') and evaluate for CAD (WMA), health of the LA (Δ LA strain), LV contractile reserve (Δ LV strain), dynamic MR, and dynamic LV outflow tract obstruction. If RV free wall strain goes down with exercise, could be a sign of dynamic pulmonary vasoconstriction during exercise (i.e., ⬆️PVR with exercise) or intrinsic RV dysfunction.

Answer to today's case: the pt had a very stiff LA, poss. due to AF ablation. But stiff LA alone cannot cause big V waves. Sympathetic activation➡️splanchnic vasoconstriction w/redistribution of volume from gut/liver➡️lungs/heart with minimal exertion + stiff LA = big V waves. This pt also had significant coronary microvascular dysfxn. Exercise➡️myocardial ischemia➡️LV diastolic dysfunction➡️increased load on LA. I tried everything to treat him, nothing worked for 7 years. And then he got an IASD as part of the @corviamedical REDUCE LAP-HF I trial.

Case: 64 yo man w/HFpEF, HTN, obesity, CAD, AF s/p ablation, NYHA 3. Invasive hemodynamics shown below. PCWP 11 at rest, ⬆️ to 32 with V waves up to 75 with 20W bike exercise. Only 1+ MR at rest/exercise. What caused the severe elevation in PCWP and V waves with minimal exercise?

#HFpEF pearl of the day: There are both "slow" and "fast" mechanisms of congestion in HFpEF patients. The "fast" mechanism is mediated by splanchnic vasoconstriction, which also may have implications for cardiorenal syndrome.

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.

#HFpEF pearl of the day: Evaluation of motion of the interventricular septum can be helpful to determine etiology/pathophys in HFpEF pts. Case: 58 yo man w/SOB, ascites, 2+ LE edema. EF 50%. Initially referred to hepatology for poss. liver failure. What did liver biopsy show?

#HFpEF pearl of the day: For echo diagnosis of ⬆️LV filling pressures, remember the 11-13-15 rule. Septal E/e' > 11 in A-fib, > 13 with exercise, > 15 at rest (in sinus rhythm) = ⬆️LV filling pressure is likely. None of these are perfect, but good rule of thumb. Here is an example of elevated septal E/e' (> 11) in AF:

Case: 63-year-old woman with long-standing rheumatoid arthritis presents with dyspnea, LE edema, fatigue. Exam JVP 12 cm, 3/6 holosystolic murmur at LSB, 1+ LE edema. LVEF 60%. TR gradient 40 mmHg, RA pressure 15 mmHg. PASP 55 mmHg. Mitral inflow: E velocity 62 cm/s, A 35 cm/s, E/A ratio 2.1.

#HFpEF pearl of the day: HFrEF is failure of the LV, HFpEF is failure of the LA. If you want to successfully manage HFpEF in your patients, you need to know at least as much about the LA as you know about the LV.

#HFpEF pearl of the day: HFpEF patients can have cardiac and extracardiac causes of volume overload. Abnormal LV GLS, reduced TDI velocities, and/or ⬆️⬆️ECG QRST angle (R axis – T axis) are clues to a more cardiac predominant phenotype.

Here’s another case: 49 yo woman w/obesity (BMI 46), HTN, OSA on CPAP, schizoaffective with new-onset HFpEF (leg swelling, dyspnea, ⬆️JVP, BNP 226 pg/ml, LVEF 65%). Low H2FPEF score = 4 (obesity, HTN meds, E/e’ = 10). What's the diagnosis? More info.... Hospitalized 6 months ago with psychotic break, treated with uptitration of anti-psychotics, now back to baseline mental status. 60-lb weight gain over past 6 mo. Also +lightheaded/dizzy. Here's the echo: