Diagnostic Criteria and Management of Heart Failure with Preserved Ejection Fraction (HFpEF)

Definition and Diagnostic Thresholds

• HFpEF is defined by a left ventricular ejection fraction ≥ 50 % together with clinical signs and symptoms of heart failure. European Society of Cardiology (ESC) guideline. 1
• An ejection fraction of 55 % satisfies the preserved‑systolic‑function criterion and excludes significant systolic dysfunction when regional wall‑motion abnormalities are absent. ESC guideline. 2

Clinical Presentation Required for Diagnosis

• Typical heart‑failure manifestations—orthopnea, paroxysmal nocturnal dyspnea, bibasilar crackles (pulmonary congestion), and an S3 gallop—are cardinal signs supporting HFpEF. ESC guideline. 3
• Left‑ventricular hypertrophy on echocardiography constitutes the structural cardiac abnormality required for HFpEF diagnosis. ESC guideline. 4

Differentiation from Other Cardiomyopathies

Heart Failure with Reduced Ejection Fraction (HFrEF)

• HFrEF is diagnosed when LVEF ≤ 40 %; an LVEF of 55 % rules out HFrEF. ESC guideline. 5

Ischemic Cardiomyopathy

• The absence of focal wall‑motion abnormalities makes ischemic cardiomyopathy unlikely, as ischemic disease typically produces regional motion defects. American College of Cardiology (ACC) guideline. 6

Pulmonary Hypertension with Right‑Ventricular Failure

• Pulmonary hypertension secondary to left‑heart disease accounts for 65–80 % of PH cases, but the lack of right‑sided signs (elevated JVP, peripheral edema, hepatomegaly, RV dysfunction) excludes primary PH‑related RV failure as the primary diagnosis. Canadian Cardiovascular Society (CCS) guideline. 7

Pathophysiologic Mechanisms

• Chronic hypertension (e.g., blood pressure ≈ 170/100 mm Hg) drives pressure overload, leading to left‑ventricular hypertrophy—the most common cause of HFpEF. ESC guideline. 8
• The combination of LVH, elevated filling pressures (evidenced by pulmonary crackles and S3 gallop), and preserved EF indicates diastolic dysfunction—impaired LV relaxation and filling. ESC guideline. 6
• Elevated intracardiac pressures are reflected by an S3 gallop and pulmonary crackles, fulfilling a diagnostic criterion for HFpEF. ACC guideline. 4

Diagnostic Nuances

• HFpEF patients often lack a dilated ventricle; instead they present with increased LV wall thickness and elevated filling pressures, making diagnosis more challenging than HFrEF. ESC guideline. 2
• A systolic ejection murmur may represent dynamic LV outflow‑tract obstruction related to hypertrophy or concurrent valvular sclerosis, both common in HFpEF. ACC guideline. 8
• Absence of primary valvular disease on echocardiography supports HFpEF secondary to hypertensive heart disease rather than valvular pathology. ESC guideline. 3

Evidence‑Based Management Priorities

• Aggressive blood‑pressure control (target <130/80 mm Hg) is a cornerstone of HFpEF management. ESC guideline. 9
• Loop diuretics are recommended to relieve congestion in symptomatic HFpEF patients. ESC guideline. 9
• Sodium‑glucose co‑transporter‑2 (SGLT2) inhibitors have demonstrated benefit across the heart‑failure spectrum, including HFpEF, and should be considered. ACC guideline. 8

Management of Heart Failure with Preserved Ejection Fraction (HFpEF) Due to Hypertensive Heart Disease

Blood Pressure Control

• The American College of Cardiology (ACC) recommends targeting a systolic/diastolic blood pressure < 130/80 mmHg in patients with HFpEF secondary to hypertension to halt left‑ventricular hypertrophy progression and improve diastolic function (Class I, Level A) 10.

Congestion Relief

• The ACC advises initiating loop diuretic therapy promptly in HFpEF patients with pulmonary congestion (e.g., orthopnea, bibasilar crackles) to achieve euvolemia while avoiding excessive volume depletion (Class I, Level A) 10.

Disease‑Modifying Pharmacotherapy

SGLT2 Inhibitors

• The ACC endorses the use of SGLT2 inhibitors (dapagliflozin or empagliflozin) for all HFpEF patients, citing the DELIVER and EMPEROR‑PRESERVED trials, which demonstrated significant reductions in cardiovascular death and HF hospitalizations (Class I, Level A) 10.

Mineralocorticoid Receptor Antagonists

• The ACC suggests adding spironolactone (or eplerenone) as part of guideline‑directed medical therapy (GDMT) in HFpEF, based on the TOPCAT trial showing modest but consistent outcome benefits, especially when additional blood‑pressure control is needed (Class IIa, Level A) 10.

Angiotensin Receptor‑Neprilysin Inhibitor (ARNI)

• The ACC notes that sacubitril/valsartan may be considered for HFpEF patients with an ejection fraction at the lower end of the preserved range (≈45‑57 %), referencing the PARAGON‑HF trial which showed benefit in this subgroup (Class IIa, Level A) 10.

Beta‑Blocker Use

• The ACC states that beta‑blockers are not routinely indicated for HFpEF unless specific comorbidities exist (e.g., recent myocardial infarction, angina, or atrial fibrillation); routine use may impair exercise tolerance due to chronotropic incompetence (Class III, Level B) 10.

Comorbidity Management

• The ACC recommends aggressive treatment of hypertension, obesity, and screening for obstructive sleep apnea as essential components of HFpEF care, with weight‑loss and exercise programs shown to improve functional capacity (Class I, Level B) 10.

Monitoring and Follow‑Up

• The ACC advises titrating GDMT to target doses while closely monitoring renal function, electrolytes, and volume status; medication adjustments should be guided by clinical response and periodic assessment of congestion (Class I, Level A) 10.

Pitfalls to Avoid

• The ACC cautions against managing HFpEF as HFrEF (e.g., routine beta‑blocker use) and warns that over‑diuresis can reduce preload in a stiff ventricle, worsening symptoms (Class III, Level B) 10.