Heart Failure with Preserved Ejection Fraction: the Major Unmet Need in Cardiology

Abstract

Heart failure with preserved ejection fraction (HFpEF) has recently been recognized as the single greatest unmet need in cardiovascular medicine. As the population ages and the comorbidity increases, the prevalence of HFpEF increases considerably. Even though there have been large numbers of studies on pathophysiology, diagnosis, and treatment of HFpEF for latest years, there are no current pharmacologic interventions that can reduce mortality. HFpEF is currently understood as a heterogeneous syndrome originated from the interplay of cardiac and extracardiac abnormalities recognized by systemic inflammation, endothelial and coronary microvascular dysfunction, cardiomyocyte dysfunction and skeletal muscle dysfunction. The difficult "jigsaw puzzle" called HFpEF has been filled with some pieces, but it is still not enough to meet clinical needs. Here, we review recent evidences and unsolved problems about HFpEF to improve our understanding of HFpEF. Finally, we hope to accelerate to completion of the problematic "jigsaw puzzle".

Keywords: Diagnosis; Heart failure with preserved ejection fraction; Pathophysiology; Syndrome; Treatment.

Figure 1. Basic concepts of diastolic HF and HFpEF.

HF = heart failure; HFpEF = heart failure with preserved ejection fraction; LV = left ventricular.

Figure 2. Phenotype classification of HF with preserved ejection fraction based on clinical presentations.

ACE = angiotensin-converting enzyme; ARB = angiotensin II receptor blocker; BNP = brain natriuretic peptide; BP = blood pressure; HF = heart failure; LV = left ventricular; PH = pulmonary hypertension; SGLT-2 = sodium-glucose cotransporter-2.

Figure 3. Phenotype classification of HFpEF based on etiology and pathophysiology.

AF = atrial fibrillation; CAD = coronary artery disease; HCM = hypertrophic cardiomyopathy; HF = heart failure; HFpEF = heart failure with preserved ejection fraction; PAH = pulmonary arterial hypertension; PDE5 = phosphodiesterase type 5.

Figure 4. Exercise-induced elevation of left ventricular filling pressure and exercise-induced PH detected by diastolic stress echocardiography.

PASP = pulmonary artery systolic pressure; PH = pulmonary hypertension; TR = tricuspid regurgitation.

Figure 5. Pathophysiologic relationship between arterial stiffness and LV dysfunction.

DBP = diastolic blood pressure; LV = left ventricular; SBP = systolic blood pressure.