Heart failure with preserved ejection fraction (HFpEF)

Overview

Heart failure with preserved ejection fraction (HFpEF) is a type of left-sided heart failure. It also may be called diastolic heart failure. The condition affects the lower left heart chamber, called the left ventricle. That chamber is the heart's main pumping chamber. In HFpEF, the left ventricle still squeezes well. But the chamber's structure has changed and it can't relax as it should. As a result, the heart has trouble filling with blood. This can lead to symptoms such as shortness of breath.

Ejection fraction is the percentage of blood leaving your heart each time it squeezes. Sometimes an ejection fraction under 50% may be a sign of heart failure. But in HFpEF, preserved means the ejection fraction is still in the standard or near-standard range.

Proper treatment may improve the symptoms of heart failure and may help some people live longer. Lifestyle changes such as not smoking and following a special heart failure diet may improve quality of life. But heart failure can be life-threatening. Some people with advanced heart failure may need a heart transplant or a device to help the heart pump blood.

Types

There are different types of heart failure. Heart failure usually affects the lower left heart chamber, called the left ventricle. This is the heart's main pumping chamber. This article focuses on a type of left-sided heart failure called heart failure with preserved ejection fraction (HFpEF). It also is called diastolic heart failure.

Another type of left-sided heart failure is heart failure with reduced ejection fraction (HFrEF) It also is called systolic heart failure.

Heart failure also can affect the lower right heart chamber, called the right ventricle. When this happens, it's called right-sided heart failure. Sometimes heart failure affects both sides of the heart.

Symptoms

If you have heart failure with preserved ejection fraction (HFpEF), also called diastolic heart failure, your heart may not supply enough blood to meet your body's needs. This is especially true during activity or exercise.

Symptoms may develop slowly. But sometimes they start suddenly. Heart failure with preserved ejection fraction (HFpEF) symptoms may include:

• Shortness of breath with activity or when lying down.
• Fatigue and weakness.
• Fast or irregular heartbeats.
• Not being able to exercise as much as you used to.
• Wheezing.
• A cough that doesn't go away or a cough that brings up white or pink mucus with spots of blood.
• Bloating or a feeling of fullness in the belly area.

Heart failure makes the body hold onto extra fluid. This can cause symptoms such as:

• Swelling in the legs, ankles and feet.
• Swelling of the belly area.
• Very fast weight gain.

Other general heart failure symptoms may include:

• Nausea and lack of appetite.
• Trouble concentrating or decreased alertness.

When to seek care

See your healthcare professional if you think you might have symptoms of heart failure. Call your healthcare professional right away if you have heart failure and:

• Your symptoms suddenly get worse.
• You develop a new heart failure symptom.
• You gain 5 pounds (2.3 kilograms) or more within a few days.
• You have new or worsening trouble doing exercise or activities.

Such changes could mean that existing heart failure is getting worse or that treatment isn't working.

When to seek emergency care

Call 911 or your local emergency number if you have any of the following:

• Chest pain that is sudden or not explained.
• Fainting or severe weakness.
• Fast or irregular heartbeats with shortness of breath, chest pain or fainting.
• Sudden, severe shortness of breath and coughing up white or pink foamy mucus.

These symptoms may be due to heart failure. But there are many other possible causes. A complete checkup with a healthcare professional is needed for an accurate diagnosis. At the emergency room, healthcare professionals do tests to learn whether your symptoms are due to heart failure or something else.

Causes

A thick or stiff lower left heart chamber can cause heart failure with preserved ejection fraction (HFpEF). The lower left heart chamber is called the left ventricle.

Many health conditions can cause the heart to get thick or stiff over time. They include:

• Coronary artery disease and heart attack. Coronary artery disease can lower blood flow to the heart muscle and lead to HFpEF. Coronary artery disease results from the buildup of fatty deposits in the arteries. The deposits narrow the arteries. This reduces blood flow and can lead to heart attack. A heart attack can cause heart muscle damage.
• High blood pressure. Also called hypertension, this condition forces the heart to work harder than it should to pump blood through the body. Over time, the extra work can make the heart muscle thick and stiff.
• Irregular heartbeats, called arrhythmias. A common irregular heartbeat in HFpEF is atrial fibrillation (AFib). It can make it harder for the heart to fill with blood and can make HFpEF worse. Treating an irregular heart rhythm may improve heart failure in some people.
• Heart valve disease. The valves of the heart keep blood flowing the right way. If a valve isn't working properly, the heart must work harder to pump blood. This may lead to heart failure. Treating some types of heart valve disease may reverse heart failure.
• Inflammation of the heart muscle, also called myocarditis. Myocarditis is most commonly caused by a virus, including the COVID-19 virus, and can lead to left-sided heart failure.
• A heart condition that you're born with, also called a congenital heart defect. If the heart and its chambers or valves haven't formed correctly, the other parts of the heart have to work harder to pump blood. This may lead to heart failure.
• Cardiac amyloidosis. This condition happens when proteins called amyloid build up in the heart. The buildup can make the heart thick and stiff and may lead to heart failure. Some types of cardiac amyloidosis are treated with medicines that target the protein buildup.
• Other health conditions. Diabetes, chronic kidney disease, obesity and sleep apnea also may lead to heart failure when not treated effectively.

Things that may trigger sudden heart failure or make heart failure worse are:

• Severe illness that affects the whole body.
• Blood clots in the lungs.
• Severe infections.
• Some medicines.
• Viruses that attack the heart muscle.

Risk factors

Some things may make you more likely to get heart failure with preserved ejection fraction (HFpEF).

General risk factors for heart failure include:

• Aging. The risk of HFpEF goes up with age. The heart's ability to work naturally goes down as people get older, even in healthy people.
• Some medicines. Examples include some chemotherapy medicines, the diabetes medicine pioglitazone (Actos), nonsteroidal anti-inflammatory drugs (NSAIDs), and some medicines used to treat conditions that affect the heart, blood, lungs, nerves or urinary system. Some medicines for mental health conditions and infections may raise the risk as well. Talk with your healthcare team about the risks and benefits of all the medicines you take.
• Alcohol use. Drinking too much alcohol may weaken the heart muscle and raise the risk of heart failure.
• Smoking or using tobacco. If you smoke, quit. Using tobacco raises the risk of heart disease and heart failure.

Diseases and conditions that raise the risk of HFpEF, also called diastolic heart failure, include:

• High blood pressure.
• Obesity.
• Diabetes.
• Coronary artery disease.
• Chronic kidney disease.
• Obstructive sleep apnea.

Complications

If you have heart failure with preserved ejection fraction (HFpEF), it's important to have regular health checkups, even if symptoms improve. Your healthcare professional can examine you and do tests to check for complications.

Complications of heart failure depend on your age, overall health and the severity of heart disease. They may include:

• High blood pressure in the lungs and right-sided heart failure. HFpEF can raise pressure in the blood vessels in the lungs. This is called pulmonary hypertension. Over time, this can lead to right-sided heart failure.
• Irregular heartbeats. Heart failure can raise the risk of irregular heartbeats. Some irregular heartbeats can make heart failure worse. Some types of irregular heartbeats can lead to a life-threatening condition called sudden cardiac arrest.
• Kidney damage or failure. Heart failure can reduce blood flow to the kidneys. Untreated, this can cause kidney failure. Kidney damage from heart failure can require dialysis for treatment.
• Liver damage. Heart failure can cause fluid buildup that puts too much pressure on the liver. This fluid backup can lead to scarring, which makes it harder for the liver to work properly.

Prevention

One way to prevent heart failure with preserved ejection fraction (HFpEF) is to treat and manage the conditions that can cause it. These conditions include coronary artery disease, high blood pressure, diabetes and obesity.

Try these heart-healthy tips:

• Eat healthy foods.
• Don't smoke.
• Stay as active as possible.
• Keep a healthy weight.
• Manage stress.
• Manage cholesterol, blood pressure and blood sugar.
• Get 7 to 9 hours of sleep daily.