What is HFpEF and what are the available treatment options?

Heart failure with preserved ejection fraction (HFpEF) is a condition in which the heart does not fill with blood properly. In HFpEF, the heart can pump normally, but the heart is stiff and cannot fill normally, causing fluid retention, shortness of breath, and leg swelling.

Heart failure is a condition where the heart does not circulate blood effectively. The heart becomes too weak or inefficient to circulate the blood the body needs. However, different underlying processes can lead to this condition, and one of the key measurements to understand is ejection fraction.

Ejection fraction is the force with which the heart’s lower-left chamber, the left ventricle, can pump blood. Some types, such as heart failure with reduced ejection fraction (HFrEF), mean the heart is too weak to pump. HFpEF means the left ventricle pumps blood with similar force to a healthy heart, keeping the ejection fraction normal.

Instead, people with HFpEF have different problems with heart function. This article explains the causes, symptoms, and treatments of these problems, as well as how HFpEF and HFrEF differ.

HFpEF is a type of heart failure in which the measurement of how efficiently the left ventricle of the heart pumps blood, or ejection fraction, is equal to or above 50%. This means that the heart pumps blood effectively but experiences issues when refilling with blood and relaxing after pumping.

This increased stiffness causes a buildup of pressure in the heart. At first, this occurs when a person engages in physical activity. However, as HFpEF worsens, high pressure can happen while they are at rest. Evidence suggests that more than half of all people with heart failure have HFpEF.

HFpEF differs from heart failure with reduced ejection fraction (HFrEF), even though they are both types of heart failure. In HFrEF, the heart is too weak to pump blood effectively. However, in HFpEF, the heart’s pumping strength remains, but it cannot stretch enough when refilling.

The muscle changes differ in the two conditions. HFpEF causes stiff, thick muscles that experience challenges when stretching to fill the ventricle before a pump. In HFrEF, the muscles become thin and stretched, meaning they become less effective at contracting.

As a result, HFrEF usually leads to an ejection fraction of 40% or less, while this is 50% or higher in people with HFpEF. The underlying causes are also different. HFrEF often occurs with conditions that weaken the heart muscle, such as long-term coronary artery disease (CAD) or a heart attack.

In the U.S., HFpEF is more common than HFrEF. Rates of HFpEF are increasing over time, while HFrEF rates are decreasing.

However, HFpEF has a complex set of causes. It is more common in women than HFrEF and has a significantly closer link to aging. A combination of different long-term health problems, including obesity, diabetes, and atrial fibrillation (AF), contributes to HFpEF more often than a single cause.

The causes of HFpEF are complex and rarely due to a single underlying cause. It develops when a combination of factors leads to stiffened left ventricle muscles, meaning that the heart can only meet the body’s needs by increasing pressure within the heart.

Older age is a highly significant factor for HFpEF. According to a 2021 review, HFpEF is one of the most common causes of needing to stay in the hospital and eventual death in people over 65 years of age. People who have HFpEF are generally older, and most people over 90 years of age who have heart failure have HFpEF.

Age also increases the risk that a person has other health problems contributing to HFpEF. These might include:

The signs and symptoms of HFpEF are similar to other types of heart failure. However, people with HFpEF may experience no symptoms or mild symptoms. Symptoms of HFpEF may include:

Diagnosing HFpEF can be challenging, as its symptoms are similar to other types of heart failure and other health conditions, including:

Treatment for HFpEF involves trying to reduce symptoms, stop the disease from getting worse, improve quality of life, prevent hospital stays, and manage underlying diseases. People with HFpEF aim to achieve this through lifestyle changes, medications, and treating acute flare-ups of symptoms known as decompensation.

Discuss any underlying conditions with a doctor, as they will need to manage these with medication or procedures to control HFpEF.

Heart failure with preserved ejection fraction (HFpEF) is a type of heart failure with close links to aging. It means that the heart’s ejection fraction, or the strength of the left ventricle’s ability to pump, remains strong. However, the pressure inside the heart increases due to problems filling the heart chambers.

HFpEF makes the ventricle’s muscles stiff, thick, and inflexible, meaning it cannot refill as effectively as before. Symptoms may include breathlessness, fatigue, and edema. A combination of underlying diseases can interact to cause HFpEF, but it does not occur due to one particular condition.

When diagnosing HFpEF, healthcare professionals expect to see high levels of a protein called NT-proBNP that suggests heart stress. Treatment includes heart-healthy lifestyle changes, medications to treat high blood pressure or reduce fluid retention, SGLT2 inhibitors, palliative care, and the management of acute symptoms as they occur.