What is the significance of preserved ejection fraction (EF)?

From the Guidelines

Heart failure with preserved ejection fraction (HFpEF) should be managed with a focus on symptom improvement, reduction of congestion with diuretics, and treatment of cardiovascular and non-cardiovascular comorbidities, as well as supervised exercise training to improve symptoms, exercise capacity, and quality of life 1.

Key Considerations

• HFpEF accounts for approximately half of all heart failure cases, with a prevalence that is increasing and outcomes that are worsening.
• Treatment focuses on managing symptoms and underlying conditions rather than improving the ejection fraction itself.
• Diuretics like furosemide are the cornerstone of therapy to reduce fluid overload and relieve symptoms.
• Additional medications include beta-blockers, ACE inhibitors, or ARBs to control blood pressure and reduce cardiac workload.
• SGLT2 inhibitors like empagliflozin have shown benefit in reducing hospitalizations.
• Lifestyle modifications are crucial, including sodium restriction, regular physical activity, weight management, and treatment of comorbidities such as hypertension, diabetes, and sleep apnea.

Pathophysiology and Management

• The pathophysiology of HFpEF involves diastolic dysfunction where the heart muscle becomes stiff, impairing relaxation and filling despite maintaining normal contraction strength.
• Supervised exercise training has been shown to improve symptoms, exercise capacity, and quality of life in patients with HFpEF, with a comparable or larger magnitude of improvement compared to those with heart failure with reduced ejection fraction 1.
• The use of SGLT2 inhibitors has been associated with reduced composite of cardiovascular death or HF hospitalizations in patients with HFpEF, as demonstrated in recent randomized controlled trials 1.

Clinical Guidelines and Recommendations

• Clinical practice guidelines recommend controlling systolic and diastolic hypertension, ventricular rate in patients with atrial fibrillation, and using diuretics to control pulmonary congestion and peripheral edema 1.
• The guidelines also suggest considering coronary revascularization in patients with coronary artery disease and symptomatic or demonstrable myocardial ischemia, as well as restoration and maintenance of sinus rhythm in patients with atrial fibrillation to improve symptoms.

From the Research

Definition and Prevalence of Preserved Ejection Fraction

• Preserved ejection fraction, also known as heart failure with preserved ejection fraction (HFpEF), is a condition where the heart's ejection fraction is normal (≥50%), but the patient still experiences symptoms of heart failure 2, 3, 4, 5.
• HFpEF accounts for approximately half of all heart failure cases, with a higher prevalence in women and the elderly 3, 4.
• The incidence of HFpEF is increasing, and it is predicted to become the leading cause of heart failure within a decade 4.

Diagnosis and Pathophysiology

• HFpEF is characterized by impaired diastolic function, concentric remodeling of the heart, and increased stiffness of the extracellular matrix and myofilaments 3, 4.
• The diagnosis of HFpEF can be challenging, especially in the outpatient setting, due to the high burden of comorbidities and difficulties in distinguishing HFpEF from normal aging 5.
• Echocardiography is a crucial diagnostic tool for HFpEF, and standardized reporting pathways can help eliminate diagnostic delays and geographical disparities 6.

Treatment and Management

• Currently, there are no approved treatments specifically indicated for HFpEF, and therapy is largely focused on managing symptoms and comorbidities 2, 3, 4, 5.
• Emerging therapeutic approaches, such as endothelial nitric oxide synthase activators and If current inhibitors, are being investigated to target diastolic dysfunction and imbalanced ventricular-arterial coupling 4.
• Primary care providers play a pivotal role in the delivery of holistic, patient-centric care for HFpEF patients, from diagnosis to management and palliative care 5.

Challenges and Future Directions

• HFpEF is a complex clinical syndrome that requires a multidisciplinary approach to management, including cardiologists, primary care providers, and other healthcare professionals 3, 5, 6.
• Further education and awareness are crucial for improving detection rates, prompt referral, and patient experience in HFpEF 6.
• Ongoing research is needed to develop effective treatments and management strategies for HFpEF, as well as to improve our understanding of the underlying pathophysiology and diagnosis of this condition 2, 3, 4, 5.