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 ischemia and tachyarrhythmia, when present.
No therapy has been shown to improve survival in randomized 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. 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). 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. 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. 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.
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.
History and exam
Key diagnostic factors
- exertional dyspnea
Other diagnostic factors
- paroxysmal nocturnal dyspnea
- abdominal fullness
- jugular venous distention
- hepatojugular reflux
- congestive hepatomegaly
- lower extremity edema
- laterally displaced apical impulse
- gallop sounds
- female sex
- age >70 years
- coronary artery disease/ischemia
- diabetes mellitus
- chronic kidney disease
- myocardial and pericardial disorders
- obstructive sleep apnea
1st investigations to order
- serum electrolytes
- renal function tests
- liver enzymes
- B-natriuretic peptide (BNP)/N-terminal prohormone B-natriuretic peptide (NT-pro-BNP)
- 12-lead ECG
- Doppler echocardiography
- tissue Doppler imaging (TDI)
Investigations to consider
- cardiac magnetic resonance (CMR) imaging
- CT angiography
- radionuclide ventriculography (MUGA scan)
- stress testing
- cardiac catheterization and coronary angiography
acute decompensated HFpEF
Gerald Carr-White, PhD, FRCP
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, and has a joint working venture with Novartis for a community pharmacist post.
Jessica Webb, BM, BCh, MA, MRCP, FHEA
Cardiology Specialist Registrar
Guys and St Thomas’ NHS Foundation Trust
JW declares that she has no competing interests.
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. GA, LT, MEDR, and KA declare that they have no competing interests.
Edward Geltman, MD
Professor of Medicine
Washington University School of Medicine
EG has lectured for Novartis, Forest, Merck, and Pfizer.
Jerry Murphy, MB, BS, DM, FRCP
Darlington Memorial Hospital
- Systolic heart failure
- Obstructive lung disease
- Idiopathic pulmonary arterial hypertension
- Chronic heart failure in adults: diagnosis and management
- 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure
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