No, CAD in HFpEF is NOT called ischemic cardiomyopathy
The term "ischemic cardiomyopathy" specifically refers to heart failure with reduced ejection fraction (HFrEF, LVEF <40%) caused by coronary artery disease, not HFpEF. When coronary artery disease occurs in patients with preserved ejection fraction (LVEF ≥50%), it remains classified as HFpEF with concurrent CAD, not ischemic cardiomyopathy 1.
Key Terminology Distinctions
The 2022 AHA/ACC/HFSA guidelines clearly define heart failure categories based on LVEF thresholds 1:
- HFrEF: LVEF ≤40% (where ischemic cardiomyopathy terminology applies)
- HFmrEF: LVEF 41-49%
- HFpEF: LVEF ≥50%
The 2023 ACC Expert Consensus explicitly states that "HFpEF is not synonymous with" other heart failure terminology, emphasizing the importance of correct classification 2.
Clinical Reality: CAD is Common in HFpEF But Changes the Phenotype
While the terminology distinction is clear, CAD is extremely prevalent in HFpEF and significantly impacts outcomes:
- 68% of HFpEF patients have angiographically-proven CAD 3
- In hospitalized HFpEF patients, 51% have obstructive epicardial CAD, with half having no prior CAD history 4
- 85% of HFpEF patients have evidence of either epicardial CAD or coronary microvascular dysfunction 4
Prognostic Implications
HFpEF patients with CAD have distinctly worse outcomes compared to those without CAD 3:
- Increased mortality (HR 1.71, p=0.04)
- Greater deterioration in ejection fraction over time
- Higher risk of transitioning to lower EF categories 5
Importantly, complete revascularization in HFpEF patients with CAD was associated with preserved cardiac function and lower mortality (HR 0.56, p=0.03) 3.
Clinical Pitfalls to Avoid
Do not assume absence of angina means absence of significant CAD. Symptoms of angina and heart failure are similar in HFpEF patients with and without CAD, as are echocardiographic measures 3. This makes clinical differentiation unreliable without objective testing.
Heart failure hospitalization is a critical trigger for ischemic events in HFpEF patients, with a 4.7-fold increased risk of ischemic events within the first month after HF hospitalization 6.
Management Approach
For HFpEF patients with documented CAD:
- Continue standard HFpEF guideline-directed medical therapy (SGLT2 inhibitors as first-line) 2
- Add anti-ischemic medications as indicated
- Consider revascularization evaluation, particularly for those with significant obstructive disease, as complete revascularization may improve outcomes 3
- Maintain heightened vigilance for ischemic events, especially peri-hospitalization 6
The presence of CAD in HFpEF represents a distinct phenotype requiring integrated management of both conditions, but the fundamental classification remains HFpEF, not ischemic cardiomyopathy.