Case 3.

Chronic dyspnea in a 71-year-old woman. A 71-year-old woman with a history of WHO grade 3 obesity (body-mass-index 40.1 kg/m²) and type 2 diabetes was referred for worsening dyspnea (NYHA grade II-III). Clinically no other signs of congestion or fluid retention were observed. The ECG showed normofrequent atrial fibrillation (A). The NT-proBNP values were increased (1190 ng/L, N < 738 ng/L). Echocardiography displayed a preserved LVEF (60%) with concentric hypertrophic remodeling and type II diastolic dysfunction. CMR confirmed the preserved LVEF (55%) with a non-dilated (B, LV end-diastolic volume: 98 mL, N = 77–158 mL; C, LV end-systolic volume: 44 mL, N = 37–48 mL) hypertrophic LV (indexed LV mass = 58 g/m², N < 55.9 g/m²), In addition, LGE imaging showed no scar (D) and a dilated LA was detected (23 cm², N < 16.0 cm²; E and F, white contouring). Rest/stress perfusion showed no sign of ischemia or scar. Consequently, the diagnosis of HFpEF was established, and an appropriate therapy consisting of diuretics and angiotensin-converting enzymes inhibitor was initiated. Interestingly, new FDA-approved classes of medication, i.e., neprilysin inhibitor and empagliflozin [231], have recently been shown to reduce cardiovascular mortality and rate of re-hospitalization for HFpEF patients, with an effect of neprilysin inhibitor persisting for higher LVEF values in women than in men [232]. Comorbidities that are associated with inflammation, such as hypertension, diabetes, and obesity, play a central role in the development of HFpEF, particularly in women [233]. In addition, a systolic LV dysfunction is increasingly recognized as being a single aspect of HF, which can also result from diastolic dysfunction as reflected in this case. Therefore, HFpEF should always be kept in mind in women with dyspnea and comorbidities that favor inflammation. Abbreviations: CMR: cardiac magnetic resonance; ECG: electrocardiogram; FDA: Food and Drug Administration; HF: heart failure; HFpEF: heart failure with preserved ejection fraction; LA: left atrium; LGE: left gadolinium enhancement; LV: left ventricle; LVEF: left ventricular ejection fraction; N: normal; NT-proBNP: N-terminal brain natriuretic peptide; WHO: World Health Organization