From the Guidelines
Heart failure with preserved ejection fraction (HFpEF) is the type of heart failure characterized by diastolic dysfunction and elevated pulmonary hypertension. This condition is marked by the heart's left ventricle maintaining normal contraction and ejection fraction (typically ≥50%), but unable to relax properly during diastole, leading to increased filling pressures 1. The diastolic dysfunction causes blood to back up into the pulmonary circulation, resulting in pulmonary hypertension. Key characteristics of HFpEF include:
- EF ≥ 50%
- Lower levels of natriuretic peptides relative to HFrEF for given elevation in left ventricular end-diastolic pressure
- Higher BMI (prevalent in HFpEF) The impaired filling patterns can be detected on echocardiography as abnormal E/A ratios, prolonged deceleration time, or elevated E/e' ratio, indicating increased left ventricular filling pressures. Pulmonary hypertension develops as a consequence of chronically elevated left atrial pressures, which transmit backward into the pulmonary venous system. Some of the key diagnostic criteria for HFpEF include:
- Symptoms and/or signs of HF caused by a structural and/or functional abnormality
- Elevated natriuretic peptides (e.g., BNP > 35 pg/mL or NT-proBNP > 125 pg/mL in ambulatory patients)
- Objective evidence of cardiogenic pulmonary or systemic congestion It is essential to note that the treatment strategies for HFpEF focus on managing symptoms, controlling hypertension, and preventing or regressing hypertrophy, with medications such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, diuretics, beta-blockers, and calcium channel blockers 1. However, the most recent and highest quality study 1 provides the most up-to-date guidance on the management of HFpEF.
From the Research
Heart Failure Characterized by Diastolic Dysfunction and Elevated Pulmonary Hypertension
- Heart failure with preserved ejection fraction (HFpEF) is a type of heart failure characterized by diastolic dysfunction and elevated pulmonary hypertension 2, 3.
- HFpEF is defined as heart failure with an ejection fraction of 50% or higher at diagnosis, and it affects approximately 3 million people in the US and up to 32 million people worldwide 2.
- Patients with HFpEF often present with dyspnea and physical examination, chest radiographic, echocardiographic, or invasive hemodynamic evidence of heart failure with overt congestion (volume overload) at rest 2.
- Elevated pulmonary hypertension is a common feature of HFpEF, and it is estimated to occur in approximately 50% of patients with HFpEF 3.
- The development of pulmonary hypertension in HFpEF is thought to be the direct consequence of reduced relaxation and enhanced stiffness of the left ventricle, leading to increased left atrial pressure 3.
Pathophysiology and Treatment
- The pathophysiology of HFpEF is complex and involves multiple factors, including diastolic dysfunction, systolic dysfunction, and vascular stiffness 4, 5.
- Treatment of HFpEF is aimed at reducing symptoms, improving quality of life, and preventing hospitalization and mortality 2, 4, 6.
- Current treatment options for HFpEF include sodium-glucose cotransporter type 2 inhibitors, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and diuretics 2, 4, 6.
- Novel therapeutic interventions, such as nitric oxide pathway-potentiating compounds, are being investigated for the treatment of pulmonary hypertension in HFpEF 3.