What is Heart Failure With Preserved Ejection Fraction (HFpEF) (Heart Failure)?

Heart failure is a health condition that happens when the heart isn’t able to pump enough blood to satisfy the body’s needs or can only do so by working much harder. This failure can be due to issues in the heart’s structure or function that prevent it from properly filling or ejecting blood. Symptoms often include breathlessness, fatigue, and congestive issues. Unfortunately, heart failure is a growing public health issue, not only in the United States but worldwide, with the risk increasing in line with advancing age. Heart failure is often progressive, and the condition can worsen over time, resulting in decreased survival rates.

The American College of Cardiology and American Heart Association (ACC/AHA) have developed a system to classify the stages of heart failure. Stage A describes people who are at risk of developing heart failure but show no symptoms as yet. Stage B refers to people with early signs of the disease. Stage C is when the disease has advanced, and patients experience symptoms. Finally, Stage D signifies advanced heart failure where patients experience severe symptoms, frequent hospitalization, and a considerable impact on their daily life.

Separately, the New York Heart Association offers a subjective assessment approach to heart failure, ranking the disease from Class I to IV, where Class I are patients who feel no symptoms to Class IV where patients experience symptoms even at rest.

Another way to classify heart failure is by considering the left ventricular ejection fraction (LVEF), which refers to the percentage of blood leaving the heart (ventricle) with each contraction. There are various categories based on LVEF, such as ‘Heart Failure with Reduced Ejection Fraction’ where the LVEF is 40% or less, ‘Heart Failure with Improved Ejection Fraction’ where a previously reduced LVEF improves to over 40%, and so on. This classification has significant bearing on how the condition will respond to treatment.

Particularly challenging to diagnose is ‘Heart Failure with Preserved Ejection Fraction’ (HFpEF), often seen in patients with evident congestion symptoms. Notably, about half of heart failure patients are classified as HFpEF, and this form can exist with different symptoms and causes. Patients with HFpEF do face higher rates of health issues and death compared to individuals without heart failure. Still, there are treatments available to control symptoms, improve quality of life, and reduce hospital stays. Medical knowledge of HFpEF continues to be studied and developed, with many clinical trials ongoing.

What Causes Heart Failure With Preserved Ejection Fraction (HFpEF) (Heart Failure)?

Heart failure happens when various diseases negatively impact the heart. In general, the most common cause of heart failure worldwide is ischaemic heart disease, which is typically due to coronary artery disease. This increases the risk of heart failure by over eight times. Other factors that can lead to heart failure are being male, smoking, overweight, diabetes, high blood pressure, and diseases of the heart valves. Social factors such as level of education, job, and income can also impact the development of heart failure.

Different forms of heart failure exhibit different risk factors and causes. Heart Failure with Preserved Ejection Fraction (HFpEF) is one example and is quite a complex condition. The most common risk factor for all types of heart failure is aging, and it is found to have a major effect on the development of HFpEF. Younger people under 65 can also develop HFpEF, which suggests that age plays a significant role in this. Additionally, atrial fibrillation (a heart rhythm disorder), being female, and any kind of pulmonary hypertension (high blood pressure in the lungs) also increase the risk of this condition. Obesity and diabetes are also significant factors in HFpEF. In particular, obesity is a major risk factor among African American and Hispanic patients.

It’s important to note that HFpEF is rarely due to a single identifiable condition but rather a combination of various risk factors. Some of these include being older, being female, having type 2 diabetes, obesity, sleep apnea, high blood pressure, pulmonary hypertension, chronic obstructive pulmonary disease, iron deficiency (with or without anemia), coronary artery disease, atrial fibrillation (irregular heartbeat), and other heart rhythm disorders.

Secondary HFpEF is caused directly by a condition that leads to heart failure. These conditions are sometimes referred to as mimics of HFpEF, and include restrictive and hypertrophic cardiomyopathies (types of heart muscle disease), pericarditis (inflammation of the heart’s outer lining), and valvular heart disease. In the United States, the most common mimic of HFpEF is left-sided valve disease.

Patients with HFpEF are particularly at risk for further heart function deterioration in the face of certain clinical conditions. These can include kidney disease, anemia (a lack of red blood cells), chronic pulmonary disease, heart rhythm disorders especially new-onset atrial fibrillation (a fast, chaotic heartbeat), infection, restricted blood flow to heart muscle, an increase in salt intake or water retention, not taking prescribed medications including blood pressure medicines or water tablets, or poorly managed blood pressure.

Risk Factors and Frequency for Heart Failure With Preserved Ejection Fraction (HFpEF) (Heart Failure)

Heart failure is a major health concern in the United States and across the globe, affecting over 60 million people worldwide. This means about 1 to 3 percent of the world’s population is living with heart failure. It’s the most common reason for hospitalization for people over 65 in the US, and hospital stays for heart failure have been on the rise from 2014 to 2017.

It’s estimated that approximately 6.7 million Americans over the age of 25 have a type of heart failure. This number is projected to rise to 8.5 million Americans by the year 2030. The chances of getting heart failure increase as people age. Lifelong risk of heart failure has gone up from about 20% to 24%, likely due to people living longer and the rise of related health conditions such as high blood pressure, diabetes, and obesity.

  • The data from the 25-year Framingham Heart Study shows that the lifelong risk of heart failure with preserved ejection fraction (HFpEF) is around 19.3%, which is higher than the 11.4% risk of heart failure with reduced ejection fraction (HFrEF).
  • This especially affects women, whose risk of HFpEF is 10.7% compared to a 5.8% risk for HFrEF. Ethnicity can affect these risks.
  • In terms of types of heart failure, cases of HFpEF are increasing, which may be due to better diagnosis methods. For example, the Framingham Heart Study saw HFpEF diagnoses go up by 53% from 2000 to 2009.
  • However, the prevalence of heart failure isn’t the same everywhere, and it can vary significantly based on geographic location. For example, in Japan, 43% of heart failure patients were diagnosed with HFpEF, but in the European Society of Cardiology long-term registry and Asian Sudden Cardiac Death in Heart Failure Registry, the prevalence of HFpEF was only 16%.

Signs and Symptoms of Heart Failure With Preserved Ejection Fraction (HFpEF) (Heart Failure)

People with Heart Failure with Preserved Ejection Fraction (HFpEF), or “diastolic heart failure,” often experience shortness of breath and fatigue, especially during physical activity. As the condition progresses, these symptoms can occur even with low levels of activity and may be accompanied by signs of fluid build-up. Some patients may not show symptoms, or their symptoms may be so mild that they go unnoticed.

Other symptoms of HFpEF are similar to those seen in different types of heart failure. Getting a detailed medical history and conducting a thorough physical examination can help classify the type of heart failure, which is crucial for deciding on the best course of treatment. However, heart failure symptoms often overlap with several other diseases. Worse heart function leads to more severe symptoms and evident signs, but no single sign or symptom is unique to heart failure.

A comprehensive medical history should include detailed information about medication, including whether the patient has been taking their medication regularly. Doctors should also inquire about risk factors for heart disease, known heart disease diagnoses, and prior heart interventions. A family history of heart failure is also important, especially if it has occurred in the previous three generations, as many heart diseases have a genetic component. Assessing the patient’s lifestyle, including tobacco and alcohol use, drug abuse, and social determinants of health, is also essential.

Commonly reported symptoms of heart failure include shortness of breath, which initially happens during activity and later while resting. Some patients might experience shortness of breath when lying flat (orthopnea) or sudden episodes of breathlessness during sleep (paroxysmal nocturnal dyspnea). A noticeable decrease in alertness or “brain fog” is not uncommon. Patients may report lesser urination during day time and increased urination at night as fluid retention worsens. Fluid can also build up in the legs, initially relieved by elevation but may eventually become a sign of severe fluid overload (pitting edema). Some patients may have discomfort in the right upper side of the stomach, loss of appetite and nausea, which can suggest decreased bowel blood flow and bowel swelling. Chest pain during physical exertion is also a common symptom.

A physical examination can help determine the severity of heart failure. Patients with isolated HFpEF who are not experiencing an acute episode are most likely to demonstrate mild systolic hypertension, and around 10% to 20% may have some degree of jugular venous distention.

Signs of severe heart failure or acute decompensation may include sweating (diaphoresis), fast heart rate (tachycardia), fast breathing rate (tachypnea), and low levels of oxygen in the blood (hypoxia). On the other hand, individuals with severe decompensation may have low blood pressure due to decreased blood flow to the body’s tissues. Listening to the heart and lungs may reveal abnormal sounds or noises. Swelling may be observed in the lower legs (pitting edema), and a swollen liver (hepatomegaly) may be noticed. Fluid build-up in the abdomen (ascites) also indicates significant fluid overload.

Testing for Heart Failure With Preserved Ejection Fraction (HFpEF) (Heart Failure)

Exertional dyspnea, or experiencing shortness of breath during physical exertion, is a common symptom. It often serves as an indicator of heart failure, but can be connected to various other diseases, making accurate diagnosis quite challenging. In patients over 60 with this symptom, along with conditions such as atrial fibrillation, chronic kidney disease, coronary artery disease, diabetes, hypertension, or obesity, heart failure with preserved ejection fraction (HFpEF) may be a possible explanantion.

To correctly identify HFpEF, certain diagnostic algorithms like HFA-PEFF and H2FPEF can come handy. These algorithms would guide medical professionals to administer additional tests such as an echocardiogram or a natriuretic peptide test. The 2022 AHA/ACC/HFSA Heart Failure Guideline also recommends a comprehensive diagnostic approach when HFpEF is suspected.

Lab tests may include full blood count, as well as measuring electrolytes, creatinine, blood urea nitrogen, and glucose levels, which all could indicate potential risk factors for heart failure. Additionally, fasting lipid profile, liver function tests, iron studies, and thyroid-stimulating hormone levels can provide insight into other potential health issues that could contribute to HFpEF. Measurement of either B-type natriuretic peptide (BNP) or N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) can help support or exclude a heart failure diagnosis, but should be used cautiously as certain factors can cause their levels to rise.

Non-invasive testing and cardiac imaging such as ECG, X-ray, and Transthoracic Echocardiography (TTE) are crucial to assess heart rhythms, cardiac shape and size, and potential lung-related diseases that may cause exertional dyspnea. They can provide valuable information to arrive at a correct diagnosis.

Treatment Options for Heart Failure With Preserved Ejection Fraction (HFpEF) (Heart Failure)

Treatment goals for HFpEF, a type of heart failure where the heart muscle doesn’t contract effectively, include reducing symptoms, improving quality of life, preventing the disease from getting worse, reducing hospital stays, and managing other health conditions that may exist. Lifestyle changes are a fundamental part of this approach.

Lifestyle Interventions

Research has shown that exercise can improve heart health and quality of life in HFpEF patients. Combining exercise with weight loss and a controlled diet can improve a patient’s physical function, exercise performance, chances of hospitalization due to heart failure, and quality of life. For older patients with obesity, combining calorie restriction and exercise has been shown to have a particularly positive effect. One study showed that a low-sodium diet, such as the DASH diet, can improve heart and artery function in patients with HFpEF and high blood pressure.

Medicine to Control Blood Pressure

If a patient’s blood pressure is not controlled, doctors often recommend medications such as diuretics, angiotensin receptor-neprilysin inhibitors (ARNIs), angiotensin receptor blockers (ARBs), and mineralocorticoid antagonists (MRAs). The target is to keep blood pressure below 130/80 mm Hg.

Some studies have shown that diuretics can reduce the risk of death and hospitalization for heart failure patients in the 30 days following hospital discharge. Beta blockers have been demonstrated to reduce mortality and provide beneficial effects for HFpEF patients.

Some medical Trials

The TOPCAT trial showed some reduction in hospitalization rates for heart failure among patients whose left ventricle ejection fraction, a measure of how well the heart pumps blood, is greater than 45%.

Another trial, PARAGON-HF, indicated that a drug called sacubitril-valsartan might lower the risk of hospitalization due to heart failure, particularly in women.

In HFpEF patients who are obese and have type 2 diabetes, some other types of medication can also be beneficial.

Rate Control in Atrial Fibrillation

Beta blockers and nondihydropyridine calcium channel blockers are commonly used to control heart rate in HFpEF patients with atrial fibrillation, a type of irregular heartbeat.

Additional Therapies

There are several other types of therapies that can be beneficial to HFpEF patients, including sleep apnea treatment, metabolic treatments, and palliative and supportive care.

Also, there are specific approaches to treating patients suffering from acutely decompensated HFpEF, which is a severe form of the condition. These include improving blood circulation with medicines, carrying out procedures to open blocked coronary arteries, and sometimes initiating renal replacement therapy or ultrafiltration for patients with severe fluid overload.

Certain medications are not recommended for these severe cases of HFpEF, including thiazolidinediones and sitagliptin or saxagliptin.

If you’re feeling short of breath or tired after exertion, it could be due to several health issues. These issues may be related to the heart or they could stem from other areas of the body.

Furthermore, many diseases can lead to heart failure, and thus when diagnosing heart failure, doctors have to consider a wide range of possible causes. However, if you experience difficulty breathing during exercise and have a risk factor or a condition that often leads to a specific type of heart failure called HFpEF, doctors may consider the following diagnoses:

  • Coronary artery disease, a condition where the blood vessels that supply oxygen and blood to the heart are blocked
  • Hypertension or high blood pressure
  • Valvular disease, especially diseases affecting the valves on the left side of the heart
  • Infiltrative cardiac diseases like amyloidosis, hemochromatosis, and sarcoidosis, which are conditions where abnormal substances accumulate in the heart tissues, causing the heart to work improperly
  • Hypertrophic cardiomyopathy, a disease where the heart muscles become abnormally thick
  • Constrictive pericarditis, a condition where the protective sac around the body’s main pump becomes inflamed and tight, affecting the heart’s function

This just goes to show how various and extensive the causes of heart-related symptoms can be, demonstrating the need for precise and careful diagnosis.

What to expect with Heart Failure With Preserved Ejection Fraction (HFpEF) (Heart Failure)

Patients with heart failure with preserved ejection fraction (HFpEF), or simply ‘heart failure where the heart pumps normally but doesn’t fill with enough blood’, often face higher rates of illness and death than those without heart failure. But, some latest studies put forward that illness rates are almost the same for patients with HFpEF and those with heart failure where the heart doesn’t pump blood effectively (HFrEF).

The presence and how severe the usual medical conditions like high blood pressure, irregular heartbeat, diabetes, and chronic kidney disease can drastically affect the future health of patients with HFpEF. There are also certain substances, called ‘biomarkers’ (like BNP, NT-pro BNP, and high-sensitivity troponin), associated with the prognosis in HFpEF. If these biomarkers are found at higher levels, it might signal a greater cardiovascular risk.

There are several factors that independently predict a worse outcome or higher chances of death in patients with HFpEF. These include:

* Advanced age
* Being male
* Having severe symptoms of heart failure (known as NYHA class C or D)
* Decreased pumping efficiency of the heart and the extent of diastolic dysfunction (when the heart doesn’t fill with blood properly)
* Extensive coronary artery disease
* Peripheral artery disease
* Diabetes
* Reduced kidney function
* High blood pressure in the lungs
* Dysfunction of the right ventricle of the heart
* Irregular heartbeat
* Increased variation in the size of red blood cells.

Possible Complications When Diagnosed with Heart Failure With Preserved Ejection Fraction (HFpEF) (Heart Failure)

Heart Failure with preserved Ejection Fraction (HFpEF) can lead to a wide range of complications due to a mix of different risk factors, complicated bodily processes, and the varying nature of this syndrome. Complications associated with heart function, such as issues with the left chamber of the heart, irregular heartbeats, and high blood pressure in the lungs, can become common. These health complexities put extra pressure on the right chamber of the heart, increasing the chance of both heart chambers failing together.

Aside from issues related to the heart, HFpEF may also cause complications related to other medical conditions, such as obesity, diabetes, and chronic kidney disease. Patients with HFpEF often have reduced exercise capability and general health decline. This happens because the body’s ability to cope with these complications decreases, leading to significant breathlessness and tiredness, which affect day-to-day activities.

Diagnosing HFpEF can be tricky due to overlapping symptoms with other conditions, making it more complex to identify in time to deliver appropriate treatments. Similarly, treatment isn’t straightforward either, as different patients have varied responses to different treatments. Hence, a personalized, team-based approach is crucial for effectively managing these complications. Researchers continue to trial new strategies to understand and manage the complications associated with HFpEF, with the goal of improving patient health and quality of life in the future.

Preventing Heart Failure With Preserved Ejection Fraction (HFpEF) (Heart Failure)

It’s important for all patients with a certain type of heart failure known as HFpEF to get counseling and education. The focus should be on taking their medication correctly and following dietary guidelines. Interestingly, not sticking to diet and medication plans are the main reasons why heart failure patients end up in the hospital again.

A better understanding of healthcare can decrease the need for emergency care due to sudden worsening of heart failure. Both single and multiple educational sessions can be beneficial for heart failure patients. However, patients who might not understand healthcare very well may find multiple sessions more helpful.

Fortunately, there are several free online resources available for patient education:

What is Heart Failure?“: An explanation with heart failure types, signs and symptoms.

Coping With Heart Failure“: Suggests lifestyle changes for better well-being and enlisting help.

Heart Failure: How to be Active“: Shows how patients with heart failure can increase their physical activity safely.

Heart Failure: Assessing Your Heart“: Discusses different tests and treatment options for heart failure.

Heart Failure: Making Changes to Your Diet“: Talks about the problems with eating too much sodium and how to avoid it.

Heart Failure: Tracking Your Weight“: Explains why tracking your weight is important and how to do it correctly.

Heart Failure: Warning Signs of a Flare-Up“: Gives information about symptoms of worsening heart failure and when to reach out to a doctor.

Taking Medicine to Control Heart Failure“: Offers strategies to help you remember to take your heart failure medication.

Frequently asked questions

Heart Failure With Preserved Ejection Fraction (HFpEF) is a form of heart failure that is particularly challenging to diagnose. It is often seen in patients with evident congestion symptoms. About half of heart failure patients are classified as HFpEF, and this form can exist with different symptoms and causes. Patients with HFpEF face higher rates of health issues and death compared to individuals without heart failure, but there are treatments available to control symptoms, improve quality of life, and reduce hospital stays.

Heart Failure with Preserved Ejection Fraction (HFpEF) is estimated to have a lifelong risk of around 19.3%, which is higher than the risk of heart failure with reduced ejection fraction (HFrEF).

Signs and symptoms of Heart Failure with Preserved Ejection Fraction (HFpEF) include: - Shortness of breath, especially during physical activity, and later while resting. - Orthopnea, which is shortness of breath when lying flat. - Paroxysmal nocturnal dyspnea, which is sudden episodes of breathlessness during sleep. - Decreased alertness or "brain fog." - Lesser urination during the day and increased urination at night as fluid retention worsens. - Fluid build-up in the legs, initially relieved by elevation, but may eventually become severe pitting edema. - Discomfort in the right upper side of the stomach, loss of appetite, and nausea, suggesting decreased bowel blood flow and bowel swelling. - Chest pain during physical exertion. - Mild systolic hypertension in patients with isolated HFpEF. - Jugular venous distention in around 10% to 20% of patients with isolated HFpEF. - Signs of severe heart failure or acute decompensation, such as sweating, fast heart rate, fast breathing rate, and low levels of oxygen in the blood. - Low blood pressure in individuals with severe decompensation due to decreased blood flow to the body's tissues. - Abnormal sounds or noises when listening to the heart and lungs. - Swelling in the lower legs (pitting edema). - Swollen liver (hepatomegaly). - Fluid build-up in the abdomen (ascites), indicating significant fluid overload.

Heart Failure With Preserved Ejection Fraction (HFpEF) can be caused by a combination of various risk factors, including aging, atrial fibrillation, being female, pulmonary hypertension, obesity, diabetes, high blood pressure, chronic obstructive pulmonary disease, iron deficiency, coronary artery disease, and other heart rhythm disorders.

The doctor needs to rule out the following conditions when diagnosing Heart Failure With Preserved Ejection Fraction (HFpEF) (Heart Failure): 1. Coronary artery disease 2. Hypertension or high blood pressure 3. Valvular disease, especially diseases affecting the valves on the left side of the heart 4. Infiltrative cardiac diseases like amyloidosis, hemochromatosis, and sarcoidosis, which are conditions where abnormal substances accumulate in the heart tissues, causing the heart to work improperly 5. Hypertrophic cardiomyopathy, a disease where the heart muscles become abnormally thick 6. Constrictive pericarditis, a condition where the protective sac around the body's main pump becomes inflamed and tight, affecting the heart's function

The types of tests that are needed for Heart Failure With Preserved Ejection Fraction (HFpEF) include: 1. Diagnostic algorithms such as HFA-PEFF and H2FPEF. 2. Echocardiogram. 3. Natriuretic peptide test (measurement of B-type natriuretic peptide or N-terminal prohormone of B-type natriuretic peptide). 4. Lab tests including full blood count, electrolyte measurement, creatinine measurement, blood urea nitrogen measurement, and glucose level measurement. 5. Fasting lipid profile. 6. Liver function tests. 7. Iron studies. 8. Thyroid-stimulating hormone level measurement. 9. Non-invasive testing and cardiac imaging such as ECG, X-ray, and Transthoracic Echocardiography (TTE).

Heart Failure with Preserved Ejection Fraction (HFpEF) is treated through a combination of lifestyle interventions, medication to control blood pressure, medical trials, rate control in atrial fibrillation, and additional therapies. Lifestyle changes, such as exercise, weight loss, and a controlled diet, can improve heart health and quality of life. Medications like diuretics, angiotensin receptor-neprilysin inhibitors (ARNIs), angiotensin receptor blockers (ARBs), and mineralocorticoid antagonists (MRAs) are used to control blood pressure. Medical trials have shown that certain drugs, such as sacubitril-valsartan, can lower the risk of hospitalization due to heart failure. Beta blockers and calcium channel blockers are used to control heart rate in patients with atrial fibrillation. Additional therapies, including sleep apnea treatment and palliative care, can also be beneficial. In severe cases, procedures to improve blood circulation and renal replacement therapy may be necessary.

Sometimes there are complications associated with treating HFpEF, such as issues with the left chamber of the heart, irregular heartbeats, high blood pressure in the lungs, reduced exercise capability, general health decline, breathlessness, and tiredness. These complications can affect day-to-day activities and decrease the body's ability to cope with other medical conditions such as obesity, diabetes, and chronic kidney disease. It is important to note that different patients may have varied responses to different treatments, so a personalized, team-based approach is crucial for effectively managing these complications.

The prognosis for Heart Failure with Preserved Ejection Fraction (HFpEF) can vary, but it is generally associated with higher rates of illness and death compared to individuals without heart failure. However, recent studies suggest that illness rates may be similar between patients with HFpEF and those with Heart Failure with Reduced Ejection Fraction (HFrEF). Factors such as age, gender, severity of symptoms, comorbidities, and biomarker levels can all impact the prognosis for HFpEF.

A cardiologist.

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