Heart failure with preserved ejection fraction (HFpEF): diagnosis and management for the general physician

Fig. 1. Contemporary model of HFpEF pathophysiology and phenotypes. HFpEF is recognised as a multisystem syndrome driven by pro-inflammatory cardiometabolic comorbidities, leading to microvascular dysfunction, myocardial stiffening and adverse remodelling. The end result is elevated left ventricular filling pressures and reduced cardiovascular reserve. Heterogeneous HFpEF phenotypes have been identified; those displayed represent commonly described, overlapping but non-exhaustive groups with varying dominant underlying mechanisms.

Fig. 2. Diagnostic approach to suspected HFpEF. The algorithm reflects contemporary guideline recommendations where diagnosis requires the presence of: i) symptoms and/or signs of HF, ii) preserved LV ejection fraction (≥50%), and iii) objective evidence of elevated left ventricular filling pressures primarily demonstrated using natriuretic testing and transthoracic echocardiography, in line with European Society of Cardiology (ESC) criteria. Where diagnostic uncertainty persists, further evaluation is recommended, alongside consideration of alternative causes of symptoms. Abbreviations: CMR, cardiac magnetic resonance imaging; CPET, cardiopulmonary exercise test; CT, computed tomography; CVD, cardiovascular disease; ECG, electrocardiogram; HFimpEF, heart failure with improved ejection fraction; HFmrEF, heart failure with mildly reduced ejection fraction (LVEF 40–49%); HFrEF, heart failure with reduced ejection fraction (LVEF <40%); LA, left atrial; LV, left ventricular; LVEF, left ventricular ejection fraction; LVH, left ventricular hypertrophy; PASP, pulmonary artery systolic pressure; PET, positron emission tomography; TR, tricuspid regurgitation. *NT-proBNP should be interpreted…

Fig. 3. Overview of chronic HFpEF management. Pragmatic approach to chronic HFpEF management, incorporating decongestion, evidence-based therapies, comorbidity optimisation, and non-pharmacological care, in line with contemporary guidelines and tailored to the individual clinical phenotype. Recommendation classes and levels of evidence are shown where applicable. Recommendation classes reflect the strength of guideline recommendations (Class I = recommended; Class IIa = should be considered; Class IIb = may be considered; Class III = not recommended). Levels of evidence (A–C) reflect the quality and quantity of supporting evidence. Abbreviations: ACC/AHA, American College of Cardiology/American Heart Association; CPAP, continuous positive airway pressure; HF, heart failure. †Evidence for non-steroidal MRAs is emerging; HFpEF guideline recommendations are awaited.