Heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is a complex clinical syndrome in which patients have symptoms and signs of heart failure, with left ventricular ejection fraction ≥50%.

The most common risk factors and comorbidities are hypertension, obesity, chronic kidney disease, diabetes mellitus, and coronary artery disease. Advanced age and female sex are also important risk factors.

Diagnosis is based on symptoms (commonly dyspnoea), clinical evidence of congestion, measurement of natriuretic peptides, and comprehensive echocardiography. Scoring systems (H₂FPEF and HFA-PEFF) are available to help discriminate HFpEF from other causes of dyspnoea.

The goals of treatment are to reduce symptoms, reduce hospitalisations, and improve patients’ functional status.

Management includes identification and treatment of underlying causes and comorbidities, implementing lifestyle measures where appropriate (exercise, diet, weight control), and pharmacotherapy including sodium-glucose cotransporter-2 inhibitors, diuretics as needed, and consideration of aldosterone antagonists, angiotensin receptor-neprilysin inhibitors, and angiotensin-II receptor antagonists.

Most patients with HFpEF can be managed by general cardiologists. However, patients who are poorly responsive to diuretic therapy, have frequent hospitalisations for heart failure, worsening end organ dysfunction, low blood pressure, and other conditions with heart failure (e.g., amyloid and constrictive pericarditis) should be cared for at a heart failure centre by a heart failure specialist.

Heart failure is a complex clinical syndrome resulting from the impaired ability of the heart to cope with the metabolic needs of the body, resulting in breathlessness, fatigue, and fluid retention. A universal definition of heart failure, proposed in 2021 by the Heart Failure Society of America, the Heart Failure Association of the European Society of Cardiology, and the Japanese Heart Failure Society, describes heart failure as 'a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion'.[1]Bozkurt B, Coats AJ, Tsutsui H, et al. Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure. 2021 Mar 1;S1071-9164(21)00050-6. https://www.doi.org/10.1016/j.cardfail.2021.01.022 http://www.ncbi.nlm.nih.gov/pubmed/33663906?tool=bestpractice.com ​

Patients with heart failure with preserved ejection fraction (HFpEF) have symptoms and signs of heart failure, with left ventricular ejection fraction (LVEF) ≥50%, not attributable to an underlying cause such as infiltrative cardiomyopathy, hypertrophic cardiomyopathy, valvular disease, pericardial disease, or high-output heart failure.[1]Bozkurt B, Coats AJ, Tsutsui H, et al. Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure. 2021 Mar 1;S1071-9164(21)00050-6. https://www.doi.org/10.1016/j.cardfail.2021.01.022 http://www.ncbi.nlm.nih.gov/pubmed/33663906?tool=bestpractice.com [2]Kittleson MM, Panjrath GS, Amancherla K, et al. 2023 ACC expert consensus decision pathway on management of heart failure with preserved ejection fraction: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2023 May 9;81(18):1835-78. https://www.sciencedirect.com/science/article/pii/S0735109723050982?via%3Dihub http://www.ncbi.nlm.nih.gov/pubmed/37137593?tool=bestpractice.com ​​​ Guidelines from the American Heart Association/American College of Cardiology/Heart Failure Society of America include evidence of spontaneous (at rest) or provokable (e.g., during exercise, fluid challenge) increased LV filling pressures (e.g., elevated natriuretic peptide, non-invasive/invasive haemodynamic measurement) in the classification of HFpEF, and the updated European Society of Cardiology guidelines include the objective evidence of cardiac structural and/or functional abnormalities consistent with the presence of LV diastolic dysfunction or raised LV filling pressure, or raised natriuretic peptides.​[3]Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation. 2022 May 3;145(18):e895-1032. https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com ​[4]McDonagh TA, Metra M, Adamo M, et al. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-726. https://academic.oup.com/eurheartj/article/42/36/3599/6358045 [5]McDonagh TA, Metra M, Adamo M, et al. 2023 focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2023 Oct 1;44(37):3627-39. https://academic.oup.com/eurheartj/article/44/37/3627/7246292 http://www.ncbi.nlm.nih.gov/pubmed/37622666?tool=bestpractice.com

In clinical practice, HFpEF was traditionally reported as diastolic heart failure. This was in comparison to 'systolic' heart failure, which is now known as heart failure with reduced ejection fraction (HFrEF). Although several abnormalities in diastolic parameters/dysfunction on echocardiogram are an integral part of the development of clinical syndrome of HFpEF, the two entities are not synonymous and diastolic dysfunction has also been shown not to be unique to HFpEF. Diastolic dysfunction on echocardiogram is also seen in systolic heart failure and in some patients with no clinical evidence of heart failure. There are several other abnormalities in HFpEF and it is now known to be a multisystem disorder involving the heart, kidneys, lungs, vascular system, skeletal muscle, immune and inflammatory signalling.[6]Youn JC, Ahn Y, Jung HO. Pathophysiology of heart failure with preserved ejection fraction. Heart Fail Clin. 2021 Jul;17(3):327-35. http://www.ncbi.nlm.nih.gov/pubmed/34051965?tool=bestpractice.com [7]Nagueh SF. Heart failure with preserved ejection fraction: insights into diagnosis and pathophysiology. Cardiovasc Res. 2021 Mar 21;117(4):999-1014. https://academic.oup.com/cardiovascres/article/117/4/999/5876832?login=false http://www.ncbi.nlm.nih.gov/pubmed/32717061?tool=bestpractice.com [8]Redfield MM, Borlaug BA. Heart failure with preserved ejection fraction: a review. JAMA. 2023 Mar 14;329(10):827-38. http://www.ncbi.nlm.nih.gov/pubmed/36917048?tool=bestpractice.com ​​​