A Case of an Elderly Patient With HFpEF

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An 82-year-old woman with longstanding hypertension, obesity, and type 2 diabetes mellitus presents for dyspnea on exertion, which has increased over several months. She denies exertional chest pain. She sleeps on two pillows and has some mild ankle edema. Her local internist referred her for additional evaluation and management. She is currently independent in her activities of daily living (ADLs), but while she is able to shop in the local supermarket, carrying her packages home has become increasingly difficult. She wants to return to her active life.

Current medications include metoprolol 25 mg bid, amlodipine 10 mg q day, amaryl 1 mg PO bid, persantine 75 mg twice a day, lorazepam 2 mg qhs, and tramadol 325 mg prn.

An electrocardiogram did not demonstrate ischemic changes. Her baseline echocardiogram showed mild left ventricular (LV) hypertrophy, with septal and posterior wall thickness of 12 mm and an LV end-diastolic dimension of 4.9 cm, with an ejection fraction (EF) of 60%. Mitral inflow pattern showed an E:A ratio of 1.3 that changed with Valsalva to an impaired relaxed pattern with a septal annular E' velocity of 7.8 cm/sec. Her resting right ventricular (RV) systolic pressure was 47 mm Hg.

She exercised for 2 minutes and 50 seconds (2.4 MET) on a Bruce protocol stress echocardiogram, stopping for extreme shortness of breath. Her resting blood pressure was 150/70 mm Hg and her heart rate was 74 bpm. At peak exercise, her blood pressure was 196/90 mm Hg, with a peak heart rate of 95 bpm. Echocardiographic images at the end of exercise demonstrated augmentation of contractility of all walls without significant mitral regurgitation. Her right ventricular systolic pressure at the end of exercise had increased to 65 mm Hg, and Doppler inflow pattern showed a monolithic E wave with a velocity of 180 cm/sec and a septal annular E' velocity of 8 cm/sec.

Which of the following statements is incorrect?

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