Chapter 19

• Symptoms and signs of heart failure with preserved left ventricular ejection fraction (LVEF > 50%).
• Presence of an underlying cause of heart failure with preserved ejection fraction (eg, comorbidities such as hypertension, coronary artery disease, diabetes, chronic kidney disease; or underlying valvular heart disease, restrictive cardiomyopathy, or specific myocardial diseases such as amyloidosis).
• The diagnosis of diastolic heart failure, which is the most common cause of heart failure with preserved ejection fraction, requires definite clinical evidence of heart failure, LVEF > 50%, and objective evidence of LV diastolic dysfunction by echocardiography or cardiac catheterization.

Heart failure with preserved ejection fraction (HFpEF) is an increasingly common, debilitating syndrome of the elderly, and it carries a high rate of morbidity and mortality. HFpEF accounts for nearly 50% of all hospitalizations for heart failure, and two large epidemiologic studies have confirmed that patients with HFpEF have a mortality rate that is nearly identical to heart failure with low ejection fraction.

HFpEF is the preferred term for patients with a normal ejection fraction who have the syndrome of heart failure, because HFpEF highlights the fact that heart failure is a syndrome and not a distinct clinical or pathophysiologic entity. Many investigators and experts have used the term “diastolic heart failure” for HFpEF in the past. However, this term is not ideal for two main reasons. First, there is ample evidence that patients with HFpEF have abnormalities in systolic function (as defined by tissue Doppler imaging), and many patients with heart failure and low ejection fraction have abnormal diastolic function. Second, in the clinical setting, patients with heart failure are currently classified into two categories: low ejection fraction (< 50%) and preserved ejection fraction (> 50%). By calling HFpEF “diastolic heart failure,” clinicians may not consider the entire differential diagnosis of HFpEF (of which pure diastolic dysfunction is only one cause). HFpEF has also previously been called “heart failure with preserved systolic function” or “heart failure with normal systolic function.” As stated above, it is now clear that many patients with HFpEF have abnormalities in systolic function; therefore, HFpEF is a better term.

The most recent American Heart Association/American College of Cardiology (AHA/ACC) guidelines have used the term “heart failure with normal ejection fraction.” This term is also not ideal because there is considerable controversy regarding the exact cutoff for a “normal” ejection fraction. Therefore, HFpEF is a slightly better term and was used in the most recent Heart Failure Society of America guidelines on the management of patients with heart failure. Finally, HFpEF has the advantage of being an easy mnemonic for patients to remember. HFpEF sounds like “HUFF-PUFF,” which helps patients understand this disease, in which dyspnea and fatigue are two of the most common symptoms.

Chinnaiyan KM et al. Curriculum in cardiology: integrated diagnosis and management of diastolic heart failure. Am Heart J. 2007 Feb;153(2):189–200.  [PubMed: 17239676]
Heart Failure Society of America. Evaluation and management of patients with heart failure and ...

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