Heart failure with preserved ejection fraction (HFpEF)

Heart failure with preserved ejection fraction (HFpEF), previously known as diastolic heart failure, is heart failure with a left ventricular ejection fraction of 50% or more. HFpEF is more common in certain population groups, including older females and patients with elevated blood pressure.

In addition to specific drug therapies, the principles of management for a patient with HFpEF are:

  • diagnose and treat the cause (eg hypertension)
  • consider underlying infiltrative cardiomyopathy (eg cardiac amyloidosis) if there is an unexplained increase in left ventricular wall thickness
  • identify and treat precipitating or exacerbating factors (eg arrhythmias such as atrial fibrillation)
  • treat the symptoms (eg diuretics to treat congestion, taking care to avoid excessive reduction in blood volume)
  • recognise and treat comorbidities (eg hypertension, coronary artery disease, diabetes).

The drugs used to treat heart failure with reduced ejection fraction (HFrEF) are often used to treat HFpEF.

The sodium-glucose co-transporter 2 inhibitors empagliflozin and dapagliflozin have been shown to decrease the combined risk of cardiovascular death and hospitalisation for heart failure in patients with HFpEFAnker, 2021Cristal Study Group, 2022. Unless contraindicated, treat patients with HFpEF with a sodium-glucose co-transporter 2 inhibitor.

While patients with HFpEF may benefit from a renin-angiotensin system inhibitor (which is often indicated for a comorbidity) and a mineralocorticoid receptor antagonist, there is insufficient evidence to recommend routine therapy with these drugs in patients with HFpEF.

Beta-blocker therapy may also be beneficial in patients with HFpEF, particularly in those with atrial fibrillation with a fast resting ventricular rate, or with coexisting coronary artery disease.

Some drugs can cause harm in patients with HFpEF; these include:

  • venodilators (eg isosorbide dinitrate), which can cause a severe reduction in cardiac output and blood pressure
  • powerful arterial vasodilators (eg hydralazine), which can cause dynamic left ventricular outflow obstruction
  • digoxin (unless the patient is in atrial fibrillation).