Heart Failure with Preserved Ejection Fraction (HFpEF) Guidelines

Introduction to HFpEF Causes

Prior myocardial infarction can lead to structural heart changes that contribute to HFpEF, particularly in patients with coronary artery disease, according to the American College of Cardiology 1
Atrial fibrillation is frequently associated with HFpEF and can both contribute to and result from HFpEF, as noted by the American College of Cardiology 2, 3

Several cardiac conditions are associated with HFpEF, including cardiac amyloidosis, hemochromatosis, Fabry disease, hypertrophic cardiomyopathy, valvular heart disease, and pericardial disease, as reported by the American College of Cardiology 2

Chronic kidney disease, liver disease, and chronic venous insufficiency are non-cardiac conditions that can contribute to HFpEF, as reported by the American College of Cardiology 2
Hypertension is the single most significant predictor for the development of HFpEF, increasing risk by approximately 50% and present in the vast majority of HFpEF patients, according to the American College of Cardiology 4
Other non-cardiac conditions associated with HFpEF include obesity, metabolic syndrome, and diabetes mellitus, which are present in a significant proportion of patients and influence exercise capacity and clinical outcomes, as reported by the American College of Cardiology 4

Advanced age is a strong predictor of HFpEF incidence, with rates up to 30% at advanced age (>80 years), and women are disproportionately affected compared to men, according to the American College of Cardiology 4 and Circulation 5
Coronary artery disease is common in HFpEF patients and is associated with greater deterioration in left ventricular systolic function and worse outcomes, as stated by the American College of Cardiology 4

Sustained hypertension leads to left ventricular hypertrophy, increased ventricular stiffness, and impaired relaxation, resulting in elevated left ventricular filling pressures, according to the American College of Cardiology 4
Elevated natriuretic peptides (BNP, NT-proBNP) predict new-onset HFpEF, and the best predictive model for new-onset HF includes NT-proBNP, troponin T, and urinary albumin excretion, as reported by Circulation 5
Pulmonary hypertension commonly develops in HFpEF due to elevated left atrial pressures, and progressive pulmonary vascular disease further complicates the condition, according to the American College of Cardiology 4

Aggressive treatment of hypertension with diuretics, ACE inhibitors, ARBs, or beta-blockers is recommended, with a target systolic blood pressure <120 mm Hg in older hypertensive patients or those at high risk, as stated by the American College of Cardiology 6
Lifestyle modifications, including weight management for obese patients, physical activity, smoking cessation, and limitation in alcohol intake, are recommended, according to the American College of Cardiology 6 and Circulation 5
Diabetes management with SGLT2 inhibitors (empagliflozin) has shown effectiveness in reducing mortality and HF hospitalizations, and avoiding medications that may increase HF risk (e.g., pioglitazone) is recommended, as reported by the American College of Cardiology 6
Biomarker monitoring, including serial monitoring of BNP/NT-proBNP and troponin, may help identify at-risk patients, according to the American College of Cardiology 6

Early intervention with aggressive blood pressure control in hypertensive patients should be prioritized to prevent HFpEF development, as stated by the American College of Cardiology 6
Risk stratification, including patients with hypertension plus other risk factors (obesity, diabetes, advanced age), should receive intensified monitoring, according to the American College of Cardiology 6
Biomarker surveillance, including periodic assessment of natriuretic peptides in high-risk patients, is recommended, as reported by the American College of Cardiology 6
A comprehensive approach, addressing all modifiable risk factors simultaneously, is necessary for maximum benefit, according to the American College of Cardiology 6