Heart Failure With Preserved Ejection Fraction (HFpEF)

Background

• Patients with HFpEF have the signs and symptoms of heart failure with a normal or near-normal ejection fraction (EF ≥ 50%).
• Approximately 50% of patients with heart failure have HFpEF and the incidence of HFpEF among heart failure patients is increasing.
• Conditions that predispose to the development of HFpEF include hypertension, aging, obesity, coronary artery disease, atrial fibrillation, and diabetes mellitus. Management of modifiable risk factors may help prevent the development of symptomatic heart failure.
• HFpEF is associated with significant 5-year mortality, particularly with increasing age.

Evaluation

• Evaluate for predisposing conditions and for the presence of symptoms and signs of heart failure.
• Differential diagnosis for HFpEF includes valvular heart disease, pericardial disorders, right heart failure, and other causes of dyspnea (such as pulmonary disease).
• Obtain the following initial tests in patients with suspected heart failure (Strong recommendation):
  • 12-lead electrocardiogram (ECG)
  • chest x-ray to evaluate heart size and pulmonary congestion and to determine alternative cardiac, pulmonary, and other diseases that may contribute to or cause symptoms
  • blood tests, including complete blood count, serum chemistries, lipid profile, liver function tests, iron studies, and thyroid-stimulating hormone
  • natriuretic peptides, to help support or exclude heart failure diagnosis
    • Patients with chronic HFpEF (particularly in patients with obesity) may have normal or falsely low B-type natriuretic peptide (BNP) or N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) levels.
    • Higher levels are associated with a positive diagnosis of heart failure but may also be due to noncardiac causes and other cardiac causes.
  • transthoracic echocardiography (TTE) for assessment of cardiac function and structure
  • if TTE is insufficient, perform additional imaging such as cardiac magnetic resonance (CMR), cardiac computed tomography (CT), or radionuclide imaging to assess left ventricular ejection fraction
• Consider right heart catheterization in patients where diagnostic uncertainty for HFpEF remains based on noninvasive imaging results and to confirm suspected pulmonary hypertension on echocardiography and its reversibility (Weak recommendation).
• Consider the use of a wireless implantable hemodynamic monitoring device in conjunction with a heart failure specialist in selected patients with HFpEF who remain symptomatic despite standard medical therapy to reduce heart-failure-related hospitalization.

Management

• Encourage lifestyle modifications including a healthy diet low in sodium and regular exercise.
• Consider supervised exercise training to improve the patient's quality of life and exercise capacity based on availability and cost.
• Use diuretics as the first-line agents to relieve symptoms of volume overload (Strong recommendation).
• Optimize the control of hypertension according to published clinical practice guidelines (Strong recommendation).
• Sodium-glucose cotransporter 2 (SGLT2) inhibitors:
  • consider use to decrease heart failure hospitalizations and cardiovascular mortality in patients with HFpEF (Weak recommendation)
  • use in patients with type 2 diabetes and heart failure to reduce heart-failure-related morbidity and mortality (Strong recommendation)
• In selected patients (particularly in patients on lower end of left ventricular ejection fraction spectrum), consider either of the following renin-angiotensin system inhibitors to decrease hospitalizations: angiotensin receptor blockers (ARB) or angiotensin receptor-neprilysin inhibitor (ARNI) (Strong recommendation).
• Consider mineralocorticoid receptor antagonists to decrease hospitalizations in selected patients, particularly in those on lower end of left ventricular ejection fraction spectrum and without hyperkalemia (Weak recommendation).
• Avoid using phosphodiesterase-5 inhibitors or nitrates to increase daily activity or quality of life (Strong recommendation).
• Treat comorbidities (whether cardiovascular or noncardiovascular) if safe and effective interventions exist to improve symptoms and prognosis, including diabetes, sleep disorders, atrial fibrillation, anemia, obesity, and coronary artery disease.