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 are advanced age, female sex, hypertension, obesity, chronic kidney disease, diabetes mellitus, and coronary artery disease.

For patients with HFpEF, the goals of treatment are to reduce symptoms, reduce hospitalizations, and improve patients’ functional status.

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%.[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 ​ Updated 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, noninvasive/invasive hemodynamic 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.[2]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-e1032. https://www.doi.org/10.1161/CIR.0000000000001063 http://www.ncbi.nlm.nih.gov/pubmed/35363499?tool=bestpractice.com [3]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://www.doi.org/10.1093/eurheartj/ehab368 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com

Over the years, HFpEF has previously been referred to as "diastolic" heart failure, or heart failure with normal ejection fraction (HFnEF). Diastolic impairment was in comparison to "systolic" heart failure, which was also known as 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. Moreover, the term "normal ejection fraction" is not correct either as some patients with HFpEF may in fact have supranormal function, such as in hypertrophic cardiomyopathy or cardiac amyloidosis, and in patients with HFpEF during exercise, with reduced long axis function and extensive but subtle changes on exercise.[3]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://www.doi.org/10.1093/eurheartj/ehab368 http://www.ncbi.nlm.nih.gov/pubmed/34447992?tool=bestpractice.com