HFpEF - heart failure with preserved ejection fraction

HFpEF

  • Symptoms of HF and elevated filling pressures at rest or with exercise, with LVEF >50%

How common?

  • Lifetime risk may be estimated from (CHS and MESA studies) to be >10% in those age >45.

  • HFpEF hospitalisations - women to men = 2:1

  • May be the dominant HF subtype in the future

  • Prevalence increases with

    • age

    • hypertension

    • obesity

    • diabetes

Pathophysiology - stiff heart

  • Hypertension -> myocardial fibrosis -> stiff heart

  • Obesity -> higher blood volume -> hypertrophy and fibrosis -> stiff heart

  • Microvascular inflammation (diabetes, obesity, CLD, hypertension) -> microvascular endothelial dysfunction -> reduced NO bioavailability, cGMP, protein kinase G activity in cardiomyocytes -> fibrosis -> stiff heart

Suggested diagnostic algorithm for HFpEF

  • Suspect HFpEF if symptoms of HF and risk factors present

    • Symptoms: dyspnoea, orthopnoea, fatigue, exercise intolerance

    • Signs: elevated JVP, oedema, pulmonary crackles

    • Often triggered by infection, AF, uncontrolled BP

  • Exclude other causes: lung disease, anaemia, obesity alone

  • Key investigations

    • ECG – AF, LVH, ischaemia

    • Bloods – BNP, renal, thyroid

    • Echo – EF ≥ 50%, LVH, LA size, diastolic parameters

    • CXR – pulmonary congestion

Multiparameters scores may be useful to highlight the important factors to consider: (https://www.jacc.org/doi/full/10.1016/j.jchf.2023.03.011)

Management

  • Address comorbidities

    • Obesity

      • >80% HFpEF pts are obese

      • Dietary intervention / bariatric surgery associated with favourable outcomes

      • Awaiting data from trials of weight lose drugs (GLP-1 agonists)

    • HTN

      • Consensus guidelines recommend <130/80mmHg

    • Diabetes

    • CAD

    • AF

      • There may be a role for rhythm control with drugs or CA in the HFpEF population (limited data)

  • Exercise

    • improves aerobic capacity and QOL

    • moderate intensity likely equivalent to higher intensities

  • SGLT2 inhibitors

    • EMPOROR-Preserved trial: 5,998 pts, empagliflozin vs placebo in HFpEF. 21% reduction  in rates of primary composite outcome of CV death or HF.

    • DELIVER trial: 6,263 pts, Dapagliflozin vs placebo in HFpEF. 18% reduction in the primary composite outcome.

  • ACEi / ARNI

    • In HFpEF generally no clinically important reductions in cardiovascular death or HF hospitalization

  • MRA

    • Spironolactone can be considered to reduce HF hospitalization in selected HFpEF patients especially those with LVEF closer to 50%; but caution re hyperK and worsened renal function

Key summary

  • HFpEF = HF symptoms +/- ↑BNP + preserved LVEF + diastolic impairment.

  • Common in older, hypertensive, AF patients

  • Early recognition and treatment reduces hospitalisations.

  • Treat HF symptoms with diuretic, manage comorbidities, control BP and encourage physical activity.

  • All patients with symptomatic HFpEF should be treated with SGLT2i (if no contraindications).
    Consider withdrawal of beta blockers in patients without compelling indication, substitute with ARB/ACEi (ARNI not subsidized in NZ….) for HTN.

Dr Gary Lau