Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF), historically termed diastolic heart failure, is a clinical syndrome of heart-failure signs and symptoms in which left ventricular ejection fraction is normal or near-normal but the ventricle fills abnormally. It is especially common in older adults, particularly older women, and accounts for roughly half of all heart-failure cases.

Definition

Heart failure with preserved ejection fraction is a syndrome of heart failure occurring despite a preserved left ventricular ejection fraction (commonly defined as 50 percent or greater), in which elevated filling pressures arise chiefly from impaired ventricular relaxation and increased ventricular stiffness (diastolic dysfunction).

Scope

The entry covers the definition of HFpEF, the physiology of impaired ventricular filling, its strong association with aging and comorbidity, and the evolving evidence base. It is a reference topic within common geriatric conditions and does not provide individualized treatment guidance.

Core questions

• What distinguishes HFpEF from heart failure with reduced ejection fraction?
• Why does impaired diastolic function cause heart-failure symptoms despite normal pumping?
• Why is HFpEF so closely associated with aging and comorbidity?
• What does the evolving trial evidence indicate about treatment of HFpEF?

Key concepts

• Diastolic dysfunction (impaired relaxation and increased stiffness)
• Preserved ejection fraction (>= 50 percent)
• Elevated left ventricular filling pressures
• Comorbidity burden (hypertension, obesity, atrial fibrillation, diabetes)
• Exercise intolerance and pulmonary congestion
• Distinction from heart failure with reduced ejection fraction

Mechanisms

In HFpEF the left ventricle contracts adequately, so ejection fraction is preserved, but it relaxes slowly and is abnormally stiff, so filling during diastole requires higher pressures. These elevated filling pressures are transmitted back to the lungs, producing exertional dyspnea and congestion. Contributing processes include left ventricular hypertrophy (often from long-standing hypertension), myocardial fibrosis, and microvascular and inflammatory changes linked to aging, obesity, and metabolic disease, which together limit the heart's ability to accommodate volume and increase output during exertion.

Clinical relevance

HFpEF is a major cause of breathlessness, hospitalization, and reduced exercise capacity in older adults, and it commonly coexists with the other common geriatric conditions such as hypertension and diabetes. Understanding its mechanism clarifies why ejection fraction can be normal yet the patient is symptomatic. This entry is for reference and education and is not a basis for individual diagnostic or treatment decisions.

Epidemiology

HFpEF accounts for approximately half of heart-failure cases, and its share has risen over time. Prevalence increases sharply with age, and the syndrome is more common in women and in people with hypertension, obesity, atrial fibrillation, and diabetes. Community cohort data showed that, unlike heart failure with reduced ejection fraction, the survival of HFpEF did not improve over the studied period.

History

Long recognized clinically as diastolic heart failure, the syndrome was sharpened by community studies in the 2000s, such as the Olmsted County analysis, which documented its high prevalence and poor outcomes. For years HFpEF lacked therapies of proven benefit, contrasting with heart failure with reduced ejection fraction; subsequent randomized trials of sodium-glucose cotransporter-2 inhibitors provided the first consistent outcome benefits in this population.

Debates

Is HFpEF one disease or a heterogeneous group of phenotypes?

HFpEF encompasses patients with diverse comorbidity-driven phenotypes, and many argue that this heterogeneity explains why trials were long neutral and that phenotype-specific approaches are needed.

Key figures

• Margaret M. Redfield
• Scott D. Solomon

Seminal works

• owan-2006
• anker-2021
• solomon-2022

Frequently asked questions

How can someone have heart failure if their ejection fraction is normal?

In HFpEF the ventricle pumps out a normal fraction of blood but fills poorly because it is stiff and relaxes slowly; the resulting high filling pressures cause congestion and breathlessness despite preserved pumping.

Why is HFpEF considered a geriatric condition?

Its prevalence rises steeply with age and it clusters with hypertension, obesity, atrial fibrillation, and diabetes, so it is encountered most often in older adults, especially older women.