Tag: atrial fibrillation

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:
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11093799/
11. Hoevelmann J. What’s New in Heart Failure? PubMed Central (PMC). 2025 Sep. Available

from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12502451/