Diagnosis and Management of Heart Failure with Preserved Ejection Fraction: 10 Key Lessons

Abstract

Heart failure with preserved ejection fraction (HFpEF) is a common clinical syndrome associated with high rates of morbidity and mortality. Due to the lack of evidence-based therapies and increasing prevalence of HFpEF, clinicians are often confronted with these patients and yet have little guidance on how to effectively diagnose and manage them. Here we offer 10 key lessons to assist with the care of patients with HFpEF: (1) Know the difference between diastolic dysfunction, diastolic heart failure, and HFpEF; (2) diagnosing HFpEF is challenging, so be thorough and consider invasive hemodynamic testing to confirm the diagnosis; (3) a normal B-type natriuretic peptide does not exclude the diagnosis of HFpEF; (4) elevated pulmonary artery systolic pressure on echocardiography in the presence of a normal ejection fraction should prompt consideration of HFpEF; (5) use dynamic testing in evaluating the possibility of HFpEF in patients with unexplained dyspnea or exercise tolerance; (6) all patients with HFpEF should be systematically evaluated for the presence of coronary artery disease; (7) use targeted treatment for HFpEF patients based on their phenotypic classification; (8) treat HFpEF patients now by treating their comorbidities; (9) understand the importance of heart rate in HFpEFlower is not always better; and (10) do not forget to consider rare diseases ("zebras") as causes for HFpEF when evaluating and treating patients. Taken together, these 10 key lessons can help clinicians care for challenging patients with HFpEF while we eagerly await the results of ongoing HFpEF clinical trials and observational studies.

Myocardial transcription factors in diastolic dysfunction: clues for model systems and disease

“…HFpEF can be considered as the new epidemic of the twenty-first century, since the prevalence of this complex clinical syndrome caused by a variety of diseases has remained high or has even increased throughout the last two decades (reviewed in [6]). Investigation into molecular mechanisms underlying HFpEF has been hampered by lack of relevant and tractable models in animals which could recapitulate phenotypic features of diastolic dysfunction in humans.…”

“…Patients with HFpEF have a normal-sized LV, often with signs of a mild hypertrophy, with impaired filling, to different degrees, due to abnormal LV relaxation and increased LV stiffness. While extra-cardiac pathophysiological conditions, such as hypertension, obesity, diabetes mellitus, renal dysfunction, and aging, can contribute to HFpEF development, a maladaptive concentric LV remodeling appears to be the main underlying substrate of impaired diastolic function in patients (recently reviewed in [1][2][3][4][5][6][7]). …”

Heart Failure With Preserved Ejection Fraction: A Perioperative Review

“…32 Differentiation of noncardiac from cardiac causes can be difficult, especially when the clinical symptoms are vague and nondescript, as HF patients commonly report to their anesthesiologist. Shortness of breath, exercise intolerance, and fatigue can have multiple causes, but these symptoms along with findings consistent with signs of HFpEF lead to the diagnosis.…”

“…32 Abbreviations: ACC/AHA, American College of Cardiologists and American Heart Association; HF, heart failture; NYHA, New York Heart Association. …”

Prognosis in heart failure with preserved ejection fraction

“…However, a large metaanalysis, including community-based studies and trials, observed lower mortality in HFpEF compared with HFrEF, though survival was still much worse than in people without HF. Among patients hospitalized for HF, the mortality rates are higher but the data are again conflicting as to whether or not the prognosis is different in HFpEF and HFrEF: [12] Among 6076 patients discharged from a Mayo Clinic Hospital in Olmsted County, Minnesota with a diagnosis of decompensated HF over a 15-year period (1987 to 2001), 53 percent had a reduced LVEF and 47 percent had a preserved LVEF. One-year mortality was relatively high in both groups but slightly lower in patients with a preserved LVEF (29 versus 32 percent in patients with reduced LVEF, adjusted hazard ratio 0.96, 95% CI 0.92-1.00).…”