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Evaluation and management of heart failure with preserved ejection fraction

Nature Reviews Cardiology volume 17, pages 559–573 (2020)Cite this article

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Abstract

Heart failure with preserved ejection fraction (HFpEF) has grown to become the dominant form of heart failure worldwide, in tandem with ageing of the general population and the increasing prevalences of obesity, diabetes mellitus and hypertension. The clinical syndrome of HFpEF is heterogeneous and must be distinguished from heart failure with reduced ejection fraction as well as other aetiologies that have different treatment strategies. The diagnosis of HFpEF is challenging and ultimately relates to the conceptual definition of heart failure as a clinical syndrome characterized by symptoms that are associated with a reduced capacity of the heart to pump blood adequately at normal filling pressures during diastole. Clinical trials to date have been largely unsuccessful in identifying effective treatments for HFpEF but evidence supports the use of diuretics, mineralocorticoid antagonists and lifestyle interventions. Pathophysiological heterogeneity in the presentation of HFpEF is substantial, and ongoing studies are underway to evaluate the optimal methods to classify patients into phenotypically homogeneous subpopulations to facilitate better individualization of treatment.

Key points

  • Heart failure with preserved ejection fraction (HFpEF) has become the most common form of heart failure, associated with substantial morbidity and mortality.

  • HFpEF is defined haemodynamically as a clinical syndrome associated with a lack of capacity of the heart to pump blood adequately without the requirement for elevated cardiac filling pressures.

  • Typical HFpEF must be distinguished from other causes of the clinical syndrome of heart failure, which are treated differently.

  • Diagnosis is challenging and requires the demonstration of objective evidence of congestion or poor cardiac output using assessment of clinical history, physical examination, natriuretic peptide testing, echocardiography data and invasive exercise testing.

  • To date, most clinical trials on the efficacy of treatments for HFpEF have produced neutral results, but strong evidence supports the use of diuretics, mineralocorticoid receptor antagonists and exercise training as effective therapies.

  • Ongoing studies are evaluating the utility of more rigorous pathophysiological characterization of HFpEF into distinct phenotypes to improve the matching of individualized treatments to patients who are most likely to respond favourably.

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Fig. 1: Diagnostic approach for HFpEF.
Fig. 2: Evidence base for the treatment of HFpEF.
Fig. 3: Phenotyping in patients with HFpEF.

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Acknowledgements

The author is supported by grants RO1 HL128526 and UO1 HL125205.

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    Barry A. Borlaug

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Borlaug, B.A. Evaluation and management of heart failure with preserved ejection fraction. Nat Rev Cardiol 17, 559–573 (2020). https://doi.org/10.1038/s41569-020-0363-2

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