Category: Original Articles

Heart Failure With Preserved Ejection Fraction and Atrial Fibrillation: Egg or the Chicken

Heart Failure with Preserved Ejection Fraction and Atrial
Fibrillation: What was first, the Egg or the Chicken?

Laiba Ejaz
Karachi Institute of Medical Sciences.

Samuel Sotelo Hernandez
Autonomous University of Durango-Cappus Zacatecas

Amin H. Karim MD
Methodist Academy of Medicine, Houston, Texas

Abstract
A 68-year-old African American man presented with recurrent lower extremity edema without dyspnea or chest pain. His history included hypertension, hyperlipidemia, and obesity. Evaluation revealed atrial fibrillation with a
controlled ventricular rate and echocardiographic findings consistent with heart failure with preserved ejection fraction (HFpEF). Secondary causes such as deep venous thrombosis were excluded. The patient was managed
with metoprolol and diuretics for rate and volume control, losartan and hydrochlorothiazide for hypertension, apixaban for anticoagulation, and amiodarone for rhythm stabilisation. After a year of persistent atrial
fibrillation, elective cardioversion successfully restored sinus rhythm following confirmation of the absence of atrial thrombus on transesophageal echocardiography. The patient remained clinically stable on subsequent
follow-up visits.

Introduction
Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) are common cardiovascular conditions that frequently coexist, particularly in older, hypertensive, and obese patients. AF can exacerbate
HFpEF by impairing atrial contribution to ventricular filling, while HFpEF may predispose to atrial remodelling and subsequent arrhythmia, creating a complex bidirectional relationship. Both conditions independently
increase morbidity and mortality and pose challenges in diagnosis and management, especially when symptoms such as edema or fatigue are subtle or overlapping. Understanding the temporal relationship between AF and
HFpEF is critical for optimizing therapy, including rate versus rhythm control, anticoagulation, and management of comorbidities. This case highlights a patient with recurrent lower extremity edema, AF, and HFpEF, raising
the clinical question of which condition preceded the other and illustrating the importance of individualized, comprehensive cardiovascular care.

Case Presentation
A 68-year-old African American man presented to the clinic with complaints of recurrent fluid buildup, mainly in his lower extremities, as noted by his primary care physician. He denied dyspnea, chest pain, orthopnea, or
paroxysmal nocturnal dyspnea. His medical history included hypertension, hyperlipidemia, and obesity. He reported occasional alcohol use and denied smoking. His family history was significant for coronary artery
disease, hypertension, hyperlipidemia, and diabetes mellitus. On examination, his weight was 280 lbs (127 kg) and height 73 inches, yielding a BMI of 37.7 kg/m2, consistent with Class I obesity. Blood pressure ranged
between 135–145/75–85 mmHg, and his pulse was irregular at 58–70 beats per minute.

Laboratory
investigations revealed a normal HbA1c and a lipid profile with total cholesterol 222 mg/dL, HDL 67 mg/dL, LDL 149 mg/dL, and triglycerides 60 mg/dL. An electrocardiogram (EKG) (figure 1) obtained during the initial
visit showed atrial fibrillation with a controlled ventricular rate of approximately 58 beats per minute. A subsequent 2D echocardiogram demonstrated a preserved left ventricular ejection fraction of 60–65% and mild
left atrial enlargement—findings consistent with heart failure with preserved ejection fraction (HFpEF). Chest X-ray showed chronic airway changes and mild atherosclerosis, while Doppler ultrasound ruled out deep
venous thrombosis. The patient was started on metoprolol and diuretics for rate and volume control, along with losartan and hydrochlorothiazide for blood pressure management. Anticoagulation with Eliquis (apixaban) and
rhythm control with amiodarone was initiated and continued for over a year without spontaneous conversion to sinus rhythm (figure 2). He subsequently underwent elective cardioversion, which successfully restored sinus
rhythm (figure 3) A transesophageal echocardiogram prior to the procedure confirmed the absence of thrombus in the left atrium or left atrial appendage. The patient continued regular follow-up and remained clinically stable
thereafter.

Discussion
This case highlights the complex interplay between atrial fibrillation (AF), hypertension, obesity, and heart failure with preserved ejection fraction (HFpEF) in an older African American male. The patient’s presentation
with peripheral edema, in the absence of dyspnea or orthopnea, emphasises that HFpEF can manifest subtly and that careful evaluation of cardiovascular risk factors and cardiac rhythm is essential for accurate diagnosis and
management (1,2). Atrial fibrillation is a common arrhythmia in elderly individuals, often associated with structural heart changes such as left atrial enlargement and diastolic dysfunction. In this patient, chronic
hypertension and obesity likely contributed to increased left ventricular stiffness and impaired relaxation, leading to diastolic dysfunction and, consequently, HFpEF (3,4). The echocardiographic findings of preserved left
ventricular ejection fraction (60–65%) with mild left atrial enlargement are consistent with this diagnosis. The irregularly irregular rhythm on electrocardiogram confirmed the presence of AF, while the controlled ventricular rate suggested adequate rate control with beta-blocker therapy (5).
HFpEF accounts for nearly half of all heart failure cases, and its prevalence continues to rise in parallel with obesity, hypertension, and metabolic syndrome (1,6). Pathophysiologically , the combination of increased
ventricular wall stress, endothelial dysfunction, and myocardial fibrosis results in elevated filling pressures despite normal systolic function (7). This leads to symptoms such as lower extremity edema, exercise intolerance, or mild dyspnea, which may fluctuate depending on volume status. Importantly, obesity is a key modifiable factor that exacerbates both HFpEF and AF by promoting systemic inflammation, left atrial remodelling, and neurohormonal activation (6,7). The management of this patient was appropriately focused on
controlling heart rate, optimizing blood pressure, managing volume status, and preventing thromboembolic events. Beta-blocker therapy (metoprolol) was effective for rate control, while diuretics addressed the peripheral
edema. Losartan and hydrochlorothiazide provided additional blood pressure control and diuresis. Given the patient’s CHA2DS2-VASc score—elevated due to age, hypertension, and heart failure—anticoagulation with
apixaban was warranted to reduce the risk of stroke, which is fivefold higher in individuals with AF (5,8). Despite more than a year of rate control and anticoagulation, the patient did not experience spontaneous
reversion to sinus rhythm. Therefore, elective cardioversion was pursued, preceded by transesophageal echocardiography to rule out intracardiac thrombus. The successful restoration of sinus rhythm improved cardiac
efficiency and potentially reduced the risk of HF progression (9). Ongoing rhythm surveillance is essential, as recurrence of AF is common, particularly in patients with underlying structural heart disease and obesity (10).
From a preventive perspective, aggressive risk factor modification remains a cornerstone of long -term management. Weight reduction, dietary sodium restriction, and increased physical activity can improve diastolic
function and reduce AF recurrence (1,2). Additionally, lipid lowering with statin therapy is indicated given the elevated LDL cholesterol level (149 mg/dL), further reducing cardiovascular risk (3,6).


In summary, this case underscores the importance of a multidisciplinary approach in managing AF and HFpEF , particularly in patients with multiple cardiovascular risk factors. Optimal control of hypertension, obesity, and
dyslipidemia, combined with rhythm management and anticoagulation, can lead to favorable clinical outcomes. The patient’s successful cardioversion and stable follow-up course demonstrate that with comprehensive care,
symptom control and maintenance of sinus rhythm are achievable in this complex patient population.

References:

  1. Kittleson MM, Panjrath GS, Amancherla K, et al. 2023 ACC Expert Consensus Decision
    Pathway on Management of Heart Failure With Preserved Ejection Fraction. J Am Coll Cardiol.
    2023;81(18):1835–78. doi:10.1016/j.jacc.2023.03.393
  2. American College of Cardiology. 2024 ACC Expert Consensus Decision Pathway on
    Clinical Assessment, Management, and Trajectory of Patients Hospitalized With Heart Failure. J Am Coll
    Cardiol. 2024. doi:10.1016/j.jacc.2024.06.002
  3. American College of Cardiology/American Heart Association. 2024 Update to the 2020
    ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure. Circ Heart Fail/HCQ.
  4. doi:10.1161/HCQ.0000000000000132
  5. Riccardi M, et al. Current Treatment of Heart Failure with Preserved Ejection Fraction. J
    Clin Med. 2025;14(15):5406. doi:10.3390/jcm14155406
  6. European Society of Cardiology. 2024 ESC Guidelines for the Management of Atrial
    Fibrillation. Eur Heart J. 2024. Available from:
    https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Atrial-Fibrillation
  7. Shahid M, et al. A Contemporary Review on Heart Failure with Preserved Ejection
    Fraction. Front Cardiovasc Med. 2024. Available from:
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12060923/
  8. Romanò M, et al. Heart Failure Syndromes: Different Definitions of Ejection Fraction and
    Implications. J Clin Med. 2025;14(14):5090. doi:10.3390/jcm14145090
  9. Spotlight on the 2024 ESC/EACTS Management of Atrial Fibrillation. Eur Heart J
    Cardiovasc Pharmacother. 2025. doi:10.1093/ehjcvp/pvad014
  10. Drug Therapy for Acute and Chronic Heart Failure with Preserved Ejection Fraction.
    PubMed Central (PMC). 2025. Available from:
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from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12502451/

Bacterial Endocarditis Prophylaxis

Dr. Pakeeza Saif
King Edward Medical College, Lahore, Pakistan


Amin H. Karim MD
Houston Methodist Academic Institute
and Weill Medical College of


Dear Dentist: My Murmur Doesn’t Need Meds Anymore!

Infective endocarditis (IE) is a serious infection of the heart’s inner lining, affecting 3 to 10 people per 100,000 annually. It carries a significant risk, with mortality reaching up to 30% within the first 30 days 1 . Staphylococcus aureus was the most frequently identified pathogen, accounting for 31% of cases. The mitral valve was the most commonly affected, involved in forty-one percent of infections, while the aortic valve was affected in thirty-eight percent of cases 2. The diagnosis of IE is primarily clinical and is based on the modified Duke criteria, which include a combination of major and minor clinical, microbiological, and echocardiographic findings.

Guntheroth et al. observed that bacteremia was present in 40% of 2,403 cases following tooth extraction, 38% of individuals during routine mastication, and 11% of those with oral sepsis in the absence of any dental intervention 3. This issue has long concerned both dentists and cardiologists, driven in part by a preference for commission bias—favoring action over inaction—when considering prophylactic antibiotic use.

American Heart Association revised the guidelines on infective endocarditis prophylaxis in 2007 (full guidelines available at http://circ.ahajournals.org ) to promote the judicious use of antibiotics, particularly in clinical scenarios where the anticipated benefits are outweighed by the risks, such as the emergence of antibiotic resistance and the potential for adverse drug reactions. The present revised document was not based on the results of a single study but rather on the collective body of evidence published in numerous studies over the past two decades. The following points were used as a rationale by AHA for updating the guideline4.

  1. IE is much more likely to result from frequent exposure to random bacteremia associated with daily activities such as chewing food, tooth brushing, flossing, use of toothpicks, use of water irrigation devices, and other activities than from bacteremia caused by a dental, gastrointestinal (GI) tract or genitourinary (GU) tract procedure.
  2. Prophylaxis prevents only an exceedingly small number of cases of IE, if any, in individuals who undergo a dental, GI tract, or GU tract procedure.
  3. The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy except in very high-risk situations.
  4. Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and thus the risk of IE and is more important than the use of prophylactic antibiotics for dental procedures 4.

Several studies have demonstrated that the lifetime risk of infective endocarditis (IE) varies significantly depending on the underlying cardiac condition. In the general population without known heart disease, the risk is approximately 5 cases per 100,000 patient-years. Patients with rheumatic heart disease (RHD) face a substantially higher risk, ranging from 380 to 440 cases per 100,000 patient-years, which is comparable to the risk observed in individuals with mechanical or bioprosthetic heart valves (308 to 383 cases per 100,000 patient-years)5 .

The greatest risks are observed in the following groups:

  • 630 cases per 100,000 patient-years following cardiac valve replacement for native valve IE
  • 740 cases per 100,000 patient-years in patients with a history of previous IE
  • 2,160 cases per 100,000 patient-years in patients undergoing prosthetic valve replacement due to prosthetic valve endocarditis

These variations in risk highlight the importance of tailoring preventive measures to individual patient profiles.

Further research indicates that even with perfect effectiveness, antibiotic prophylaxis would prevent only a negligible number of infective endocarditis cases—given that the estimated absolute risk after a dental procedure is about 1 in 1.1 million for mitral valve prolapse, 1 in 475 000 for congenital heart disease, 1 in 142 000 for rheumatic heart disease, 1 in 114 000 for prosthetic heart valves, and 1 in 95 000 for those with a history of endocarditis6 7 .

Cardiac Conditions Associated with the Highest Risk of Adverse Outcome from Endocarditis for Which Prophylaxis Is Reasonable

  • Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
  • Previous Infective Endocarditis
  • Cardiac transplantation recipients who develop cardiac valvulopathy
  • Congenital heart disease (CHD)
  • Unrepaired cyanotic CHD, including palliative shunts and conduits
  • Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure
  • Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device.

Guidelines also clearly stated that antibiotic prophylaxis is no longer recommended for any other form of congenital heart disease which explicitly includesheart murmurs, valvular regurgitation, or stenosis without prosthetic material or prior endocarditis 4.

Preventing Infective Endocarditis: Procedures Requiring Antimicrobial Prophylaxis

High-Risk Procedures Requiring Antibiotic Prophylaxis

  • Dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa
  • Respiratory tract procedure with incision and biopsy such as tonsillectomy and adenoidectomy
  • Gastrointestinal or genitourinary procedures in setting of active infection
  • Surgery on infected skin, skin structure, or musculoskeletal tissue

Low-Risk Procedures Not Requiring Antibiotic Prophylaxis

  • Gastrointestinal or Genitourinary procedure in the absence of infection
  • Most Vaginal deliveries or Caesarian deliveries
  • Left atrial appendage occlusion device placement (e.g., Watchman) in the absence of infection — associated with a very low incidence of infective endocarditis, with long-term studies showing no device-related infections over extended follow-up. A single center, 14 year study of 181 patients found no device-related infections over more than 500 patient years of follow up8 .
  • Stable cardiac implantable electronic devices (CIEDs) such as pacemakers and ICDs — antibiotic prophylaxis is not recommended for dental or mucosal procedures solely due to the presence of a CIED in the absence of other high-risk cardiac conditions9 .
  • Atrial septal defect (ASD) closure devices beyond 6 months post-implantation — prophylaxis is not indicated once the device is fully endothelialized and no residual shunt remains10 .

Infective Endocarditis Prophylaxis: Antibiotic Recommendations

  • First line: 2 g amoxicillin orally (or 50 mg/kg kids) 30–60 minutes before the procedure.
  • If allergic to penicillin, 600 mg clindamycin orally (or 20 mg/kg kids).
  • Alternatives include 500 mg azithromycin or clarithromycin orally (15 mg/kg kids)
  • If you can’t take pills, get 2 g ampicillin IM/IV (or 50 mg/kg kids)

Considering rising antimicrobial resistance and the potential for Clostridioides difficile infection linked to antibiotic use, it is advised against relying on the outdated “better safe than sorry” approach to prophylactic antibiotic use, as it may cause more harm than benefit to patients.

References

1. Mostaghim AS, Lo HYA, Khardori N. A retrospective epidemiologic study to define risk factors, microbiology, and clinical outcomes of infective endocarditis in a large tertiary-care teaching hospital. SAGE Open Med. 2017;5. doi:10.1177/2050312117741772

2. Murdoch DR. Clinical Presentation, Etiology, and Outcome of Infective Endocarditis in the 21st Century. Arch Intern Med. 2009;169(5):463. doi:10.1001/archinternmed.2008.603

3. Guntheroth WG. How important are dental procedures as a cause of infective endocarditis? Am J Cardiol. 1984;54(7):797-801. doi:10.1016/S0002-9149(84)80211-8

4. Wilson W, Taubert KA, Gewitz M, et al. Prevention of Infective Endocarditis. Circulation. 2007;116(15):1736-1754. doi:10.1161/CIRCULATIONAHA.106.183095

5. Steckelberg JM; WWR. Risk factors for infective endocarditis. Infectious disease clinics of North America. 1993;7(1):9-19.

6. Pallasch TJ, Wahl MJ. Focal infection: new age or ancient history? Endod Topics. 2003;4(1):32-45. doi:10.1034/j.1601-1546.2003.00002.x

7. Pallasch TJ. Antibiotic prophylaxis: problems in paradise. Dent Clin North Am. 2003;47(4):665-679. doi:10.1016/S0011-8532(03)00037-5

8. Ward RC, McGill T, Adel F, et al. Infection Rate and Outcomes of Watchman Devices: Results from a Single-Center 14-Year Experience. Biomed Hub. 2021;6(2):59-62. doi:10.1159/000516400

9. Canpolat U. Tailored antibiotic prophylaxis in patients undergoing CIED implantation: One size does not fit all the principle. Pacing and Clinical Electrophysiology. 2019;42(4):483-483. doi:10.1111/pace.13624

10. Tanabe Y, Sato Y, Izumo M, et al. Endothelialization of an Amplatzer Septal Occluder Device 6 Months Post Implantation: Is This Enough Time? An In Vivo Angioscopic Assessment. Journal of Invasive Cardiology. 2019;31(2). doi:10.25270/jic/18.00206