June 19, 2026AJP Heart and Circulatory Physiology
Heart Failure with Preserved Ejection Fraction as a Syndrome of Reduced Effective Stroke Volume
Key result
Review frames HFpEF as a syndrome of reduced effective stroke volume driving impaired systemic perfusion.
Why the study?
Traditional characterization of HFpEF as a disorder of diastolic dysfunction does not fully explain the dissociation between preserved LVEF and impaired functional capacity.
Key Points
- Evaluate the hypothesis that HFpEF results from reduced effective stroke volume despite preserved LVEF.
- Conceptual analysis of heart failure mechanisms including myocardial stiffness and diastolic suction.
- Review of physiological and clinical observations supporting the altered perspective of HFpEF.
- Identified structural remodeling and increased myocardial stiffness contribute to impaired ventricular filling.
- Demonstrated that preserved LVEF may coexist with limited cardiac output reserve and neurohormonal activation in certain patients.
PICO
P
Population
Heart failure with preserved ejection fraction (HFpEF)
Proposes a conceptual framework for HFpEF as a syndrome of reduced effective stroke volume rather than solely a disorder of diastolic dysfunction.
Implication
Questions exclusive diastolic focus in HFpEF; leaves open whether stroke volume augmentation improves outcomes.
Abstract
Heart failure with preserved ejection fraction (HFpEF) is traditionally characterized as a disorder of diastolic dysfunction. However, this framework does not fully explain the dissociation between preserved left ventricular ejection fraction (LVEF) and impaired functional capacity. HFpEF may be conceptualized as a syndrome of reduced effective stroke volume despite preserved LVEF. Structural remodeling, increased myocardial stiffness, and impaired diastolic suction contribute to limited ventricular filling, while preserved circumferential and radial mechanics may help maintain LVEF in some patients. This can result in a mismatch between forward flow and filling pressures, which may contribute to limited cardiac output reserve and, in a subset of patients, neurohormonal activation and congestion. This perspective is supported by existing physiological and clinical observations. HFpEF may present as a phenotype characterized by impaired systemic perfusion and elevated filling pressures in many patients, although significant heterogeneity exists.
AJP Heart · literature review. HFpEF may be a stroke volume problem, not just diastolic dysfunction. Heart Failure with Preserved Ejection Fraction as a Syndrome of Reduced Effective Stroke Volume Why does preserved LVEF coexist with impaired functional capacity? How effective stroke volume may fall: Remodeling and myocardial stiffness → Impaired ventricular filling → Reduced effective stroke volume → Impaired systemic perfusion. Preserved LVEF can mask limited reserve: Preserved LVEF, Limited output reserve, Neurohormonal activation, Elevated filling pressures. Bottom line: Questions an exclusive diastolic focus; whether boosting stroke volume helps remains open.
Discussion
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Cite This Study
André Timóteo Sapalo (2026) conducted a review in Heart failure with preserved ejection fraction (HFpEF). Heart failure with preserved ejection fraction may be conceptualized as a syndrome of reduced effective stroke volume, leading to impaired systemic perfusion and elevated filling pressures.