Heart failure with preserved ejection fraction: diagnosis, risk assessment, and treatment

Abstract

The aetiology of heart failure with preserved ejection fraction (HFpEF) is heterogenous and overlaps with that of several comorbidities like atrial fibrillation, diabetes mellitus, chronic kidney disease, valvular heart disease, iron deficiency, or sarcopenia. The diagnosis of HFpEF involves evaluating cardiac dysfunction through imaging techniques and assessing increased left ventricular filling pressure, which can be measured directly or estimated through various proxies including natriuretic peptides. To better narrow down the differential diagnosis of HFpEF, European and American heart failure guidelines advocate the use of different algorithms including comorbidities that require diagnosis and rigorous treatment during the evaluation process. Therapeutic recommendations differ between guidelines. Whilst sodium glucose transporter 2 inhibitors have a solid evidence base, the recommendations differ with regard to the use of inhibitors of the renin-angiotensin-aldosterone axis. Unless indicated for specific comorbidities, the use of beta-blockers should be discouraged in HFpEF. The aim of this article is to provide an overview of the current state of the art in HFpEF diagnosis, clinical evaluation, and treatment.

Keywords: Diagnosis; Diastolic; Heart failure; Preserved ejection fraction; Treatment.

Fig. 1

HFpEF phenotypes with upper and lower boundary of the estimated prevalence values. Modified from Anker et al. [4] COPD, chronic obstructive pulmonary disease; MR, mitral regurgitation; TR, tricuspid regurgitation

Fig. 2

Clinical scores estimating the likelihood of a HFpEF diagnosis. Modified from Pieske et al. [5] (left panel) and Reddy et al. [7] (right panel). CT, computed tomography; ECG, electrocardiogram; PET, positron emission tomography

Fig. 3

Components of assessing the contributors to dyspnoea in patients with confirmed diagnosis of HFpEF according to the HFA-PEFF or the H₂FPEF score. Cut-off values were ≥ 5 and ≥ 6, respectively. Modified from Verwerft et al. [8] CAD, coronary artery disease; CMR, cardiac magnetic resonance imaging; CPET, cardiopulmonary exercise test; CT, computed tomography; ECG, electrocardiogram; PVI, pulmonary vein isolation

Fig. 4

Relative prevalence and HFpEF patients’ age at onset caused by systemic disease. Modified from Kubo et al. [154] ATTRwt, wild-type transthyretin amyloidosis; ATTRh, hereditary transthyretin amyloidosis; HNCM, hypertrophic non-obstructive cardiomyopathy; HOCM, hypertrophic obstructive cardiomyopathy