Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction, known internationally as HFpEF, is heart failure with a left ventricular ejection fraction of 50% or more. Ejection fraction is the percentage of blood in the left ventricle that is pumped out with each heartbeat. In this type the number is normal, but the muscle of the left ventricle is stiff and does not stretch easily as it fills with blood.

Because it is hard to fill, the pressure inside the heart rises, especially during activity, when the heart has to fill faster. That pressure is passed back to the blood vessels of the lungs, causing shortness of breath. This is why the main complaints in this type are shortness of breath and tiring quickly when moving, while at rest you may feel fine.

Who Gets It

This type accounts for about half of all heart failure cases and is more common in older adults and women. It usually comes with other conditions: hypertension, obesity, diabetes, atrial fibrillation, chronic kidney disease, and sleep apnea. These coexisting conditions trigger inflammation and stiffness in the heart muscle and blood vessels. For this reason, this type is seen as a whole-body disease, not just a heart disease. Each person may have a different mix of coexisting conditions, so the treatment plan is tailored accordingly.

Why It Is Often Recognized Late

Because the ejection fraction result is normal, symptoms are often blamed on age, body weight, or lung disease. Tests at rest may also look almost normal, because the pressure inside the heart only rises clearly during activity. Diagnosis requires additional evidence from echocardiography and an NT-proBNP test, and sometimes a stress test or right heart catheterization. Doctors also look for specific causes that mimic this type, such as amyloidosis and hypertrophic cardiomyopathy, because their treatment is different. Amyloidosis is covered on the Cardiac Amyloidosis page.

Treatment Approach

The 2023 ESC guideline update recommends SGLT2 inhibitors because they reduce hospitalizations for heart failure. Diuretics relieve fluid congestion. Other equally important parts are controlling blood pressure, treating atrial fibrillation, losing weight if you are overweight, and regular physical exercise, which has been shown to improve exercise capacity and quality of life. Treating this type is a joint effort between cardiologists and the doctors who manage the coexisting conditions.

Doctors look for three things: symptoms or signs of heart failure, an ejection fraction of 50% or more, and evidence that the filling pressure of the heart is raised. This evidence comes from echocardiography, for example an enlarged left atrium, thickened ventricular walls, or an impaired filling pattern, and from high levels of NT-proBNP or BNP. In people with obesity, NT-proBNP levels can be lower, so they need to be interpreted with care.

If the results at rest are not clear, your doctor may recommend a stress echocardiogram or right heart catheterization to measure the pressure directly. Scores such as H2FPEF and HFA-PEFF help weigh the likelihood. Doctors also rule out other causes of shortness of breath, such as lung disease, anemia, and coronary disease, and look for specific causes such as amyloidosis with cardiac MRI or bone scintigraphy.

Many people think shortness of breath during activity is just a sign of age or lack of exercise. See a cardiologist if this symptom is new or getting worse, especially if you have hypertension, diabetes, obesity, or atrial fibrillation. If you have already been diagnosed, contact your doctor early if any of the following occurs.

• Your weight goes up by 2 kg or more in 3 days.
• Shortness of breath or swelling is worse than usual.
• Your heart beats irregularly.
• Your blood pressure at home is often well above target.
• Go to the emergency room right away if you have severe shortness of breath at rest, chest pain, or fainting.