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Heart failure with preserved ejection fraction

Last reviewed: 4 Sep 2023
Last updated: 22 Mar 2023



History and exam

Key diagnostic factors

  • exertional dyspnea
More key diagnostic factors

Other diagnostic factors

  • orthopnea
  • paroxysmal nocturnal dyspnea
  • abdominal fullness
  • rales
  • jugular venous distention
  • hepatojugular reflux
  • congestive hepatomegaly
  • lower extremity edema
  • laterally displaced apical impulse
  • gallop sounds
Other diagnostic factors

Risk factors

  • hypertension
  • atrial fibrillation
  • female sex
  • age >70 years
  • obesity
  • coronary artery disease/ischemia
  • diabetes mellitus
  • chronic kidney disease
  • myocardial and pericardial disorders
  • obstructive sleep apnea
More risk factors

Diagnostic investigations

1st investigations to order

  • serum electrolytes
  • renal function tests
  • liver enzymes
  • B-natriuretic peptide (BNP)/N-terminal prohormone B-natriuretic peptide (NT-pro-BNP)
  • CBC and iron studies
  • 12-lead ECG
  • blood glucose
  • thyroid function tests
  • blood lipids
  • CXR
  • transthoracic echocardiography
More 1st investigations to order

Investigations to consider

  • cardiac magnetic resonance (CMR) imaging
  • CT angiography
  • radionuclide ventriculography (MUGA scan)
  • stress testing
  • cardiopulmonary exercise testing (CPET)
  • cardiac catheterization and coronary angiography
More investigations to consider

Treatment algorithm


all patients



Gerald Carr-White, PhD, FRCP

Consultant Cardiologist

Guys and St Thomas’ NHS Foundation Trust




GCW has been reimbursed by Pfizer, Astra Zenica, Bayer, Medtronic, St Jude, and Sanofi for attending conferences. He has attended Advisory Boards for Medtronic, St Jude, Novartis, Shire, Sanofi, and Servier.

Jessica Webb, PhD, FRCP, FESC, FHEA

Consultant Cardiologist

Guys and St Thomas’ NHS Foundation Trust




JW has a joint working venture with BI for a community pharmacist post.


Dr Gerald Carr-White and Dr Jessica Webb would like to gratefully acknowledge Dr Gerard Aurigemma, Dr Lokesh Tejwani, Dr Marc E. Del Rosario, and Dr Kul Aggarwal, previous contributors to this topic. We would also like to thank Dr Syed Wamique Yusuf for his review of the topic.


GA, LT, MEDR, and KA declare that they have no competing interests.

Peer reviewers

Edward Geltman, MD

Professor of Medicine

Cardiovascular Division

Washington University School of Medicine

St. Louis



EG has lectured for Novartis, Forest, Merck, and Pfizer.

Jerry Murphy, MB, BS, DM, FRCP

Consultant Cardiologist

Darlington Memorial Hospital




Not disclosed.

  • Heart failure with preserved ejection fraction images
  • Differentials

    • Systolic heart failure
    • Obstructive lung disease
    • Idiopathic pulmonary arterial hypertension
    More Differentials
  • Guidelines

    • 2022 AHA/ACC/HFSA guideline for the management of heart failure
    • 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction
    More Guidelines
  • Patient leaflets

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    COPD: what treatments work?

    More Patient leaflets
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