Chapter 27. Heart Failure with Preserved Ejection Fraction

• Symptoms and signs of heart failure with preserved left ventricular ejection fraction (LVEF > 50%).
• Presence of an underlying cause of heart failure with preserved ejection fraction (eg, comorbidities such as hypertension, coronary artery disease, diabetes, chronic kidney disease; or underlying valvular heart disease, restrictive cardiomyopathy, or specific myocardial diseases such as amyloidosis).
• Objective evidence of elevated left ventricular filling pressure (at rest or with exercise) on echocardiography or cardiac catheterization.

Heart failure with preserved ejection fraction (HFpEF) is an increasingly common, debilitating syndrome of the elderly, and one that carries a high rate of morbidity and mortality. HFpEF accounts for > 50% of all hospitalizations for heart failure, and while a recent patient-level meta-analysis found that patients with heart failure and reduced ejection fraction (HFrEF) have a worse prognosis compared to HFpEF, two earlier large epidemiologic studies found that patients with HFpEF have a mortality rate that is nearly identical to HFrEF. Regardless of underlying ejection fraction, survival for all heart failure (HF) patients is poor, especially after HF hospitalization.

HFpEF is the preferred term for patients with a normal ejection fraction who have the syndrome of HF, because HFpEF highlights the fact that HF is a syndrome and not a distinct clinical or pathophysiologic entity. Many investigators and experts have used the term “diastolic heart failure” for HFpEF in the past. However, this term is not ideal for two main reasons. First, there is ample evidence that patients with HFpEF have abnormalities in systolic function (as defined by tissue Doppler imaging) despite a normal ejection fraction, and many patients with HFrEF have abnormal diastolic function. Second, in the clinical setting, patients with HF are currently classified into two categories: low ejection fraction (< 50%) and preserved ejection fraction (> 50%). By calling HFpEF “diastolic HF,” clinicians may not consider the entire differential diagnosis of HFpEF (of which pure diastolic dysfunction is only one cause). HFpEF has also previously been called “HF with preserved systolic function” or “HF with normal systolic function.” As stated earlier, it is now clear that many patients with HFpEF have abnormalities in systolic function; therefore, HFpEF is a better term.

Finally, HFpEF has the advantage of being an easy mnemonic for patients to remember. HFpEF sounds like “HUFF-PUFF,” which helps patients understand this syndrome, in which dyspnea and fatigue are two of the most common symptoms.

Since HFpEF is heterogeneous, there is no single mechanism that can explain the pathophysiology of ...