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Heart Failure With Preserved Ejection Fraction: An Overview

Heart Failure With Preserved Ejection Fraction: An Overview

Heart failure (HF) is a complex, disabling, and prevalent disease. According to the American Heart Assocation (AHA) Heart Disease and Stroke Statistics 2020 update, an estimated 6.2 million adult Americans are affected by HF. The prevalence of HF continues to rise, and with a projection of over 8 million cases by 2030, HF will remain a significant and growing public health burden.

Approximately 50% of patients with HF have heart failure with preserved ejection fraction (HFpEF). According to the AHA, the prevalence of HFpEF compared with heart failure with reduced ejection fraction (HFrEF) appears to be increasing along with the aging population. In the next decade, it is expected that HFpEF will become the more dominant form of HF worldwide. Unfortunately, many large, randomized trials of therapies that demonstrated improved outcomes in HFrEF have failed to show benefits in HFpEF. The purpose of this post is to review the basics of HFpEF, including predisposing factors, pathophysiology, diagnosis, and therapies.

What Is HFpEF?

The simplistic definition of HFpEF is HF with a left ventricular (LV) ejection fraction (EF) of ≥50%. It is a type of HF clinical syndrome that results from a functional and structural impairment of contraction or filling of the heart.

Common Risk Factors/Comorbidities in HFpEF

  • Hypertension
  • Diabetes
  • Coronary artery disease
  • Atrial fibrillation

Multimorbidity is higher in HFpEF than in HFrEF. Nearly 50% of patients with HFpEF have ≥5 comorbidities.

Overview of HFpEF Pathophysiology

HFpEF is heterogenous from a pathophysiologic perspective. There are multiple pathophysiologic aspects that are involved in the development of HFpEF. HFpEF risk factors are known for causing tissue and cellular pathology, which includes systemic inflammation, myocardial ischemia, tissue fibrosis, altered cell signaling, and myocyte hypertrophy. These changes result in structural remodeling, leading to decreased LV functional reserve. The decrease in LV functional reserve causes decreased lusitropy, chronotropy, and inotropy—leading to abnormal hemodynamics. Changes in hemodynamics include increased LV filling pressure and decreased perfusion. These changes result in congestion and lung dysfunction, decreased renal perfusion, left atrial/LV dysfunction, right ventricular remodeling and dysfunction, and microvascular dysfunction: Hence, the clinical syndrome of HFpEF.

Evaluation and Diagnosis of HFpEF

The diagnosis of HFpEF can be challenging because it mainly involves excluding non-cardiac causes of symptoms suggestive of HF. Current guidelines support using an EF of ≥50% as one of the main components of the diagnostic algorithm, along with detection of cardiac abnormalities to explain the symptoms. The Heart Failure Society of America/European Society of Cardiology recommend using the PEFF stepwise approach to HFpEF diagnosis:

  1. (P) Pretest Assessment: Assess signs/symptoms of HF, comorbidities; obtain and assess EKG, standard echocardiogram, natriuretic peptide, and cardiopulmonary stress test
  2. (E) Diagnostic Work-up: Comprehensive echocardiogram, labs (eg, natriuretic peptide if not done in step 1)
  3. (F1) Advanced Work-up: Exercise echocardiography, invasive hemodynamic measurement
  4. (F2) Etiological Work-up: Cardiac imaging such as cardiac MRI; consider native heart biopsy, genetic testing, and other specific labs

Management of HFpEF

The management of HFpEF revolves around the goals of controlling symptoms such as managing fluid overload (especially in the acute phase), improving quality of life, and treating underlying disease. For patients with refractory HF symptoms, referral to disease management programs, advanced HF centers, and pulmonary artery catheter guided management should be strongly considered.

References
  • Dunlay S, Roger V, Redfield M. Epidemiology of heart failure with preserved ejection fraction. Nat Rev Cardiol. 2017;14:591–602.
  • Gevaert A, Boen J, Segers V, Van Craenenbroeck E. Heart failure with preserved ejection fractions: a review of cardiac and noncardiac pathophysiology. Frontiers in Physiology. 2019;10:1-14.
  • Pfeffer M, Shah A, Borlaugh B. Heart failure with preserved ejection fraction in perspective. Circulation Research. 2019;124:1598-1617.
  • Pieske B, Tschope C, deBoer R, et al. How to diagnose heart failure with preserved ejection fraction; the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). European Heart Journal. 2019;40:3297-3317.
  • Virani SS, Alonso A, Benjamin EJ, et al.Heart disease and stroke statistics-2020 update: A report from the American Heart Association. Circulation. 2020;141:e139–e596.
  • Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Journal of the American College of Cardiology. 2013;62:e147-e239.

Filed under: Cardiometabolic

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