Heart failure with preserved ejection fraction (HFPEF), or diastolic heart failure (HF), refers to the clinical syndrome of HF coupled with evidence of diastolic dysfunction and is associated with significant mortality and morbidity [1]. The incidence of HFPEF has been variedly described between 30 and 50% among patients with heart failure [2]. The goals of care for perioperative management of these patients include maintenance of adequate preload, slower heart rate to accommodate for adequate diastolic filling time, and avoidance of hypertension to decrease the afterload to the left ventricle. The association of acute myocardial infarction with perioperative HFPEF is rare but can have disastrous consequences. We describe the case of acute HFPEF presenting as a harbinger of myocardial infarction in the perioperative period.

۲٫ Case Description

A 63-year-old male, weighing 82 kg (BMI 28), was scheduled for abdominoperineal resection (APR) and right partial hepatectomy for metastatic colon cancer. His past medical history was significant for hypertension, recently diagnosed noninsulin dependent diabetes, a cerebral vascular accident 9 years prior to surgery, an 80-pack year smoking history (quit 20 years prior to surgery), and an episode of acute congestive heart failure with preserved ejection fraction approximately one year before surgery. At preoperative evaluation, the patient described his functional capacity as excellent (able to climb 2 flights of stairs multiple times a day with no symptoms; worked more than 60 hrs. a week as a mechanic) and denied any symptoms of HF. The physical examination did not reveal any signs of congestive heart failure. Transthoracic echocardiogram (TTE) showed normal left ventricular (LV) size and function (EF of 55%) and no significant valvular pathology. Since the patient was scheduled for an intermediate risk surgery, had no active cardiac conditions, and had good functional capacity, a decision was made to proceed with surgery without further work-up based on guidelines established by the American College of Cardiology and the American Heart association (ACC/AHA).