Heart failure with preserved ejection fraction (HFpEF) is a complex clinical condition. Initially called diastolic heart failure, it soon became clear that this condition is more than the opposite side of systolic heart failure. It is increasingly prevalent and lethal. Currently, HFpEF represents more than 50% of heart failure cases and shares a 90-day mortality and readmission rate similar to heart failure with reduced ejection fraction. Heart failure with preserved ejection fraction is best considered to be a systemic disease. From a cardiovascular standpoint, it is not just a stiff ventricle. A stiff ventricle combined with a stiff arterial and venous system account for the clinical manifestations of flash pulmonary edema and the marked changes in renal function or systemic blood pressure with minor changes in fluid volume status. No effective pharmacologic treatments are available for patients with HFpEF, but an approach to the musculoskeletal system has merit: the functional limitations and exercise intolerance that patients experience are largely due to abnormalities of peripheral vascular function and skeletal muscle dysfunction. Regular exercise training has strong objective evidence to support its use to improve quality of life and functional capacity for patients with HFpEF. This clinical review summarizes the current evidence on the pathophysiologic aspects, diagnosis, and management of HFpEF.

PURPOSE: Heart Failure (HF) is more prevalent in African Americans (AAs) than in Non Hispanic whites and imposes a higher rate of morbidity, mortality and 30-day readmissions. In general cohorts, AAs have also been shown to have a higher prevalence of concomitant comorbidities including chronic obstructive pulmonary disease (COPD), pulmonary hypertension (PH) and others. However, there is paucity of data looking at the impact of these conditions in AAs with acute decompensated heart failure (ADHF). The purpose of this study is to describe clinical characteristics, comorbidities, indices of cardiac structure and function, and their impact on 30-day readmission rates in an urban AA population admitted with ADHF. METHODS: A retrospective cohort analysis was conducted using data from AA patients admitted to our facility with a diagnosis of ADHF from 1/1/14 to 3/31/14. 30-day readmission incidence was documented if a patient was admitted for any cause, within 30 days of their index admission, to one of our 4 affiliate hospitals in Chicago, including ours. Chi-square, t-test, Fishers exact and multivariate regression models were applied to determine predictors of readmission including patient demographics, comorbidities, laboratory data and Doppler echocardiographic indices. RESULTS: 140 AA patients were admitted with a diagnosis of ADHF during the study period of which 84 (60%) comprised of heart failure with preserved ejection fraction (HFpEF) and 56 (40%) of heart failure with reduced ejection fraction (HFrEF). Overall, 31 (22.1%) patients were readmitted within 30 days of which 22 (71%) were of HFpEF and 9 (29%) of HFrEF variety. Patients who were readmitted were significantly older (73.03 AE 2.7, p<0.02), more likely to have COPD (40.5%, p<0.002), higher pulmonary artery systolic pressure (PASP) (45.82 AE 2.1, p<0.001) and higher tricuspid regurgitant velocity (TRV) (3.08 AE 0.13, p<0.001) on Doppler echocardiography along with elevated serum N-terminal pro-brain natriuretic peptide (NT-proBNP) (31.3%, p<0.001), compared to those who were not readmitted. Multivariate regression model revealed significant independent predictors of 30-day readmission including a prior diagnosis of COPD (OR: 3.62, p<0.01), a combination of PASP greater than 36 mmHg and TRV greater than 2.8 m/s (OR: 5.27, p<0.001), elevated NT-proBNP (OR: 4.24, p<0.02), and age greater than 70 years (OR: 3.08, p<0.02). CONCLUSIONS: Advanced age, COPD, PH and elevated NT-proBNP are associated with higher incidence of 30-day readmission among AA patients with ADHF. CLINICAL IMPLICATIONS: Identification and optimization of characteristics associated with HF readmissions prior to discharge can potentially reduce HF related morbidity, mortality and overall healthcare expenditure.