Applied Evidence

Heart failure: Best options when ejection fraction is preserved

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With few trials focusing on diastolic heart failure, the authors turned to studies of patients with a reduced ejection fraction, as well as consensus and experience, to create this review.




Suspect diastolic heart failure in patients who have symptoms of heart failure but a normal ejection fraction, with or without evidence of diastolic abnormalities. B

Treatment goals for patients who have heart failure with preserved ejection fraction (HFPEF) include normalization of blood pressure, prevention of tachycardia and ischemia, reduction of congestion, and improvement in exercise capacity. B

Initiate beta-blocker therapy without delay for patients who have acute decompensated HFPEF and tachycardia; consider cardioversion for those with atrial fibrillation. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Most studies of heart failure (HF)—the most common cause of hospitalization in patients older than 65 years1—have focused on patients with reduced ejection fraction (EF). Yet half of those hospitalized for acute decompensated HF have a normal left ventricular EF.2 For these patients, contractility is not the problem—impaired relaxation during diastole is.

Commonly called diastolic HF, heart failure with preserved ejection fraction (HFPEF) is a more precise name for this condition. Patients are usually older than those with a reduced EF.3 Thus, as the US population ages, the prevalence of HFPEF increases, as well.4

Diagnostic criteria have been developed for HFPEF, but there are few large, high-quality studies to guide its treatment. Yet family physicians need to be familiar with HFPEF and know how best to treat it. With extrapolation from studies of patients with reduced EF, as well as expert consensus and our own experience, we offer an evidence-based approach to the management of both stable and acute decompensated HFPEF.

A closer look at diastolic dysfunction

Defined as an abnormality of diastolic compliance, filling, or relaxation of the ventricle, diastolic dysfunction can occur whether EF is normal or abnormal.3 Ventricular diastole includes isovolumic relaxation, early passive filling after mitral valve opening, and active filling during atrial contraction. Transmission of high ventricular pressure to the pulmonary circulation leads to pulmonary edema, dyspnea, and other symptoms of HF. Factors other than abnormal diastolic physiology, such as chronic volume overload, ventricular coupling dyssynchrony, increased autonomic tone leading to reduced venous capacitance, and chronotropic intolerance, may also be involved.5

Patient history: What to look for
A variety of conditions, including ischemia, tachycardia, impaired myocardial relaxation, and age-related loss of myocardial compliance, can contribute to abnormal diastolic function, but the major causes of HFPEF are chronic hypertension, hypertrophic cardiomyopathy, and coronary artery disease (CAD).3 Rarely, infiltrative or restrictive cardiomyopathy (eg, amyloidosis or sarcoidosis) is implicated.6 Noncardiovascular comorbidities such as diabetes, renal impairment, anemia, and chronic lung disease are more prevalent among those with HFPEF, and more women are affected than men.1

Mortality risk. In a study of more than 100,000 hospitalizations for acute decompensated HF, patients with preserved EF had lower in-hospital mortality (3% vs 4% for those with reduced EF).2 Patients with both diabetes and CAD commonly develop HFPEF,7 and the presence of these comorbidities are an independent predictor of 5-year mortality.8

Population studies suggest that 5-year mortality rates for African Americans with HFPEF are higher than for Caucasians with this condition.9 Other predictors of mortality include older age, male sex, lower left ventricular EF, ischemic disease, impaired renal function, and peripheral arterial disease.10-12

Diagnosing HFPEF: What you’ll see, when to test

The presentation of patients with HFPEF is similar to that of individuals with reduced EF. In an outpatient setting, both groups will have reduced exercise capacity; increased neuroendocrine activation, which may cause chronic fluid retention, vasoconstriction, and tachycardia; and a reduced quality of life.5

Neither the American College of Cardiology/American Heart Association (ACC/AHA) nor the Heart Failure Society of America (HFSA)13,14 recommends screening for asymptomatic left ventricular dysfunction. For those with signs and symptoms of HF, however, echocardiography is a key component of the initial evaluation. Echocardiography provides information about left ventricular systolic function, including EF, regional wall motion abnormalities, and wall thickness. Echocardiographic evidence of diastolic abnormalities is found for some patients with HFPEF, while others have no demonstrable diastolic dysfunction.3

While an electrocardiogram (EKG) cannot distinguish between HF with reduced EF and HFPEF, common findings might include signs of ventricular hypertrophy or tachycardia during acute exacerbations. An EKG should be obtained in patients with suspected HF to screen for antecedent causes such as hypertrophy, atrial fibrillation, and ischemia.15


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