Heart Failure With Preserved Ejection Fraction
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Direct answer
Heart failure with preserved ejection fraction is clinical heart failure with a left ventricular ejection fraction of 50 per cent or more, driven mainly by impaired ventricular relaxation and raised filling pressures rather than weak contraction. Diagnosis requires symptoms and signs, elevated natriuretic peptides and evidence of diastolic abnormality on echocardiography, and treatment remains largely symptomatic, centring on diuretics, blood pressure and rate control, and SGLT2 inhibitors.
What you must remember
- Definition: ejection fraction of 50 per cent or above; 41 to 49 per cent is mildly reduced, and a previously reduced fraction that has risen by 10 points or more to above 40 per cent is improved.
- Natriuretic peptides: BNP above 35 pg/mL or NT-proBNP above 125 pg/mL in sinus rhythm supports the diagnosis, and higher thresholds apply in atrial fibrillation.
- Echo criteria: average E/e′ above 14, tricuspid regurgitant velocity above 2.8 m/s, left atrial volume index above 34 mL/m² and septal e′ below 7 cm/s.
- Grading: grade I is impaired relaxation with E below A; grade II is pseudonormal filling; grade III is restrictive, with E/A of 2 or more and deceleration time under 160 ms.
- Differentials: hypertrophic cardiomyopathy, cardiac amyloidosis, hypertensive heart disease, atrial fibrillation, ischaemia and valvular disease all mimic the picture.
- Diuretics: loop diuretics relieve congestion, but preload is sensitive, so over-diuresis causes hypotension and pre-renal kidney injury.
- SGLT2 inhibitors: empagliflozin and dapagliflozin reduce hospitalisation for heart failure in trials of preserved ejection fraction, and current European guidance supports their use.
A worked diagnosis in an obese hypertensive woman
A 71-year-old woman with obesity and long-standing hypertension is breathless climbing stairs, with ankle oedema and a BNP of 320 pg/mL. Her ejection fraction is 58 per cent, average E/e′ is 16, and the left atrial volume index is raised. These findings fulfil the criteria for heart failure with preserved ejection fraction. The next step is to exclude mimics. Cardiac amyloidosis is suspected if the ECG shows low voltage despite left ventricular hypertrophy on echo, and a hypertrophic cardiomyopathy pattern prompts specialist review.
Treatment proceeds on several fronts simultaneously. Diuretics are titrated to relieve congestion and stopped short of dehydration. Blood pressure is controlled, since hypertension drives the stiffening of the ventricle. An SGLT2 inhibitor is added, weight reduction is encouraged, and atrial fibrillation is screened for and rate-controlled if present. Exercise and cardiac rehabilitation are offered where feasible. Unlike reduced ejection fraction, there is no single pillar with proven mortality benefit, so the strategy is to relieve symptoms, prevent hospitalisation and treat every contributor to the raised filling pressure.
Where the exam tries to catch you
The first trap is the belief that a normal ejection fraction excludes heart failure. Symptoms, signs and natriuretic peptides define it, and a candidate who rules out heart failure on the ejection fraction alone has misread the question. The second is the overuse of diuretics, which candidates push as if preload were fixed. In HFpEF, the ventricle fills poorly, so small reductions in preload can drop output sharply.
A third trap is the amyloidosis clue: low voltage on ECG with left ventricular hypertrophy on echo points away from hypertensive heart disease. Indian examinations also test whether candidates know that the evidence for disease-modifying drugs is far thinner than in reduced ejection fraction, so the honest answer is symptomatic management with the best available supportive agents.
Frequently asked questions
What ejection fraction defines heart failure with preserved ejection fraction?
Heart failure with preserved ejection fraction is defined by a left ventricular ejection fraction of 50 per cent or more, together with symptoms and signs of heart failure. Mildly reduced fractions of 41 to 49 per cent fall into a separate intermediate category.
Which echocardiographic parameter best indicates raised filling pressure?
An average E/e′ ratio above 14 indicates raised left ventricular filling pressure in heart failure with preserved ejection fraction. It is combined with tricuspid regurgitant velocity and left atrial volume index to build the diagnostic picture.
Which natriuretic peptide thresholds support the diagnosis of HFpEF?
BNP above 35 pg/mL or NT-proBNP above 125 pg/mL supports the diagnosis in sinus rhythm, and higher thresholds apply in atrial fibrillation. A normal value makes the diagnosis less likely but does not exclude it on its own.
Which drug class has the strongest evidence for reducing hospitalisation in HFpEF?
SGLT2 inhibitors, such as empagliflozin and dapagliflozin, have the strongest evidence for reducing heart failure hospitalisation in preserved ejection fraction. Mineralocorticoid antagonists and sacubitril-valsartan offer more limited benefit in this group.