Do Heart Failure (HF) with Preserved Ejection Fraction (PEF) and Reduced Ejection Fraction (REF) present differently?

From the Guidelines

Heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) present differently, with HFpEF patients tend to be older, more often female, and have higher rates of hypertension, atrial fibrillation, and obesity, while HFrEF patients are more likely to be male with a history of coronary artery disease or prior myocardial infarction. The diagnosis of HFpEF is more challenging than the diagnosis of HFrEF, as patients with HFpEF generally do not have a dilated LV, but instead often have an increase in LV wall thickness and/or increased left atrial (LA) size as a sign of increased filling pressures 1.

Key Differences

• Patients with HFpEF tend to have more peripheral edema and their symptoms may be more pronounced with exertion, while HFrEF patients may exhibit more pronounced left ventricular enlargement on imaging and have more significant systolic dysfunction.
• Laboratory findings can be similar, though natriuretic peptide levels are typically higher in HFrEF.
• The distinction is important because treatment approaches differ significantly, with HFrEF having more established guideline-directed medical therapies including ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, while HFpEF management focuses more on treating underlying conditions and symptoms 1.

Clinical Implications

• The diagnosis of HFpEF and HFrEF requires a comprehensive evaluation of the patient's symptoms, medical history, and laboratory findings.
• Treatment approaches should be tailored to the specific type of heart failure, with a focus on improving symptoms and reducing morbidity and mortality.
• Further research is needed to better understand the underlying mechanisms and optimal treatment strategies for HFpEF and HFrEF.

Management Strategies

• For HFpEF, management focuses on treating underlying conditions such as hypertension, atrial fibrillation, and obesity, as well as symptoms such as shortness of breath and fatigue.
• For HFrEF, management includes guideline-directed medical therapies such as ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, as well as devices such as implantable cardioverter-defibrillators and cardiac resynchronization therapy.

From the Research

Presentation of Heart Failure with Preserved Ejection Fraction (HFpEF) and Heart Failure with Reduced Ejection Fraction (HFrEF)

• HFpEF and HFrEF present differently in terms of symptoms, diagnosis, and treatment [(2,3,4,5,6)].
• Approximately half of all patients with heart failure have a preserved ejection fraction, and the prevalence is growing rapidly [(2,3,5)].
• HFpEF is characterized by symptoms and signs of heart failure with normal or near-normal left ventricular ejection fraction (LVEF ≥50%) [(5,6)].

Diagnostic Challenges

• Diagnosis of HFpEF in the outpatient setting presents unique challenges compared with HFrEF due to factors including a high burden of comorbidities in HFpEF and difficulties in distinguishing HFpEF from normal aging [(3,4,6)].
• Differentiating HFpEF from other causes of dyspnea may require advanced diagnostic methods, such as exercise echocardiography, invasive haemodynamics, and investigations for 'HFpEF mimickers' [(4,6)].

Treatment Strategies

• There are few effective treatments currently identified for HFpEF, and these are limited to decongestion by diuretics, promotion of a healthy active lifestyle, and management of comorbidities [(2,3)].
• Sodium-glucose cotransporter 2 inhibitors, such as dapagliflozin or empagliflozin, have been shown to reduce the risk of composite cardiovascular events in HFpEF [(4,6)].
• Exercise training and diet-induced weight loss have produced clinically meaningful increases in functional capacity and quality of life in randomized clinical trials 6.

Prognosis and Management

• HFpEF has a high morbidity and mortality rate, with patients being hospitalized approximately 1.4 times per year and having an annual mortality rate of approximately 15% 6.
• Comprehensive management of HFpEF includes exercise, treatment of risk factors and comorbidities, and education in HF self-care 6.
• Classification based on phenotypes may facilitate a more targeted approach to treatment than LVEF categorization, which sets arbitrary cut-points when LVEF is a continuum 4.