Heart failure with preserved ejection fraction

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.

Approximately half of patients with heart failure have normal, or near-normal, left ventricular ejection fraction and are classified as having heart failure with preserved ejection fraction.

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

Patients may present with acute decompensated heart failure and are generally managed with diuresis, blood pressure control, and treatment of ischaemia and tachyarrhythmia, when present.

No therapy has been shown to improve survival in randomised control trials. Risk factor modification and diuretics where there is evidence of fluid overload are the cornerstones of long-term management.

Heart failure (HF) 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.

HFpEF was previously referred to as 'diastolic' HF. This was in comparison to 'systolic' HF, which corresponded with heart failure with reduced ejection fraction (HFrEF). However, diastolic dysfunction has been shown not to be unique to HFpEF, as evidence of diastolic dysfunction may also be found in systolic heart failure. The term 'heart failure with normal ejection fraction' (HFnEF) was used briefly, although newer imaging techniques have confirmed that systolic function in HFpEF patients is not completely normal, with reduced long axis function and extensive but subtle changes on exercise.[1]Sanderson JE. HFNEF, HFpEF, HF-PEF, or DHF: what is in an acronym? JACC Heart Fail. 2014 Feb;2(1):93-4. http://heartfailure.onlinejacc.org/content/2/1/93 http://www.ncbi.nlm.nih.gov/pubmed/24622122?tool=bestpractice.com As the exact range of normal function is difficult to define and the left ventricular function is not thought to be entirely normal in these patients, the term 'HFpEF' has now been adopted.

Patients with HFpEF have the clinical signs of heart failure with normal or near-normal left ventricular function and no significant valvular abnormalities (i.e., no significant aortic stenosis or mitral regurgitation).[2]Vasan RS, Levy D. Defining diastolic heart failure: a call for standardized diagnostic criteria. Circulation. 2000 May 2;101(17):2118-21. http://circ.ahajournals.org/content/101/17/2118.full http://www.ncbi.nlm.nih.gov/pubmed/10790356?tool=bestpractice.com The exact pathophysiology of HFpEF remains uncertain, although impaired isovolumetric ventricular relaxation, decreased left ventricular compliance, and increased left ventricle passive stiffness are consistently reported among all patients.[3]Zile MR, Baicu CF, Gaasch WH. Diastolic heart failure - abnormalities in active relaxation and passive stiffness of the left ventricle. N Engl J Med. 2004 May 6;350(19):1953-9. http://www.nejm.org/doi/full/10.1056/NEJMoa032566#t=article http://www.ncbi.nlm.nih.gov/pubmed/15128895?tool=bestpractice.com [4]Sharma K, Kass DA. Heart failure with preserved ejection fraction: mechanisms, clinical features, and therapies. Circ Res. 2014 Jun 20;115(1):79-96. http://circres.ahajournals.org/content/115/1/79.long http://www.ncbi.nlm.nih.gov/pubmed/24951759?tool=bestpractice.com Patients often have overlapping comorbidities, and it has only recently been convincingly demonstrated that HFpEF represents more than a sum of all its comorbidities and is a condition in its own right.[5]Mohammed SF, Borlaug BA, Roger VL, et al. Comorbidity and ventricular and vascular structure and function in heart failure with preserved ejection fraction: a community-based study. Circ Heart Fail. 2012 Nov;5(6):710-9. http://circheartfailure.ahajournals.org/content/5/6/710.long http://www.ncbi.nlm.nih.gov/pubmed/23076838?tool=bestpractice.com HFpEF is likely to be due to diastolic dysfunction, impaired systolic function on exercise, abnormal ventricular-arterial coupling, inflammation and endothelial dysfunction, chronotropic incompetence, altered myocardial energetics and peripheral skeletal muscle metabolism and perfusion, pulmonary hypertension, and renal insufficiency.[4]Sharma K, Kass DA. Heart failure with preserved ejection fraction: mechanisms, clinical features, and therapies. Circ Res. 2014 Jun 20;115(1):79-96. http://circres.ahajournals.org/content/115/1/79.long http://www.ncbi.nlm.nih.gov/pubmed/24951759?tool=bestpractice.com

In 2016, the European Society of Cardiology updated their diagnostic guidelines, introducing a third category, heart failure with mid-range ejection fraction (HFmrEF). This resulted in defining HFpEF as patients with symptoms and signs of heart failure, raised natriuretic peptides, left ventricular ejection fraction (LVEF) >50%, and structural heart disease and/or diastolic dysfunction. HFrEF is defined as LVEF <40%, with HFmrEF as LVEF 41% to 49% with structural heart disease and/or diastolic dysfunction.[6]Ponikowski P, Voors AA, Anker SD, et al; Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur J Heart Fail. 2016 Aug;18(8):891-975. http://onlinelibrary.wiley.com/doi/10.1002/ejhf.592/full http://www.ncbi.nlm.nih.gov/pubmed/27207191?tool=bestpractice.com