Heart failure with normal ejection fraction: current diagnostic and management strategies

Abstract

Heart failure with normal ejection fraction (HFNEF), previously known as diastolic heart failure (HF), is defined as a syndrome of HF with normal or near normal ejection fraction (≥50%) and evidence of abnormal left ventricular (LV) diastolic function. It represents about 50% of patients diagnosed with HF. HFNEF is not a benign disease as it carries a morbidity and mortality risk as high as that associated with HF and reduced ejection fraction (HFREF). HFNEF shares some risk factors, hemodynamic consequences and clinical presentations with HFREF, though they differ in the pathophysiology and cardiac morphology. Therapies such as β-blockers (BBs) and angiotensin-receptor blockers (ARBs), which are beneficial in HFREF have not shown a survival benefit in HFNEF. Therapies focus on control of hypertension, control of heart rate, revascularization in case of ischemia for long term management and use of diuretics in acute decompensated HFNEF. Exercise therapy improves performance in HFNEF.

Keywords::

• aldosterone antagonists
• β-blockers
• diastolic dysfunction
• ejection fraction
• exercise training
• heart failure
• hypertension
• obesity
• RAS inhibitors
• tissue Doppler
• trans-mitral flow velocities

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Heart failure (HF) with normal ejection fraction (HFNEF) is common and accounts for about 50% of patients with HF, both in the community and inpatient settings.

• • Despite preserved ejection fraction, it is associated with high mortality, driven by severity of HF severity.

• • The diagnosis of HFNEF is based on diagnosing the clinical syndrome of HF, demonstration of HF ≥50% and evidence of abnormal left ventricular (LV) diastolic performance.

• • The principal abnormalities lie in the process of early myocardial relaxation and late diastolic LV stiffness, but pericardium and intrathoracic pressures play important roles in LV filling as well.

• • Principles of management include achievement of euvolemic status to relieve pulmonary congestion, slowing of heart rate to increase LV filling time, restoration of atrial kick and control or reversal of pathogenetic mechanisms such as hypertension and myocardial ischemia.

• • Neurohormonal blockade with β-blockers, angiotensin-receptor blockers and spironolactone have not resulted in an improvement of its natural history.

• • Exercise training improves LV filling pressures and exercise tolerance indicating possible reversal of abnormal LV mechanics with exercise.

  Gaining further insights into molecular and cellular basis of myocardial stiffening are crucial to find effective therapeutic strategies.

Notes