Diagnosis and Management of Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) accounts for roughly half of all heart failure cases and poses unique diagnostic and therapeutic challenges. Patients with HFpEF exhibit symptoms of congestion or exercise intolerance despite a left ventricular ejection fraction at or above 50%. The pathophysiology is heterogeneous, involving diastolic dysfunction, microvascular inflammation and maladaptive ventricular–arterial coupling. Common comorbidities such as hypertension, atrial fibrillation, obesity and chronic kidney disease further complicate the clinical picture. Diagnosis relies on a combination of clinical assessment, biomarker measurement—most notably natriuretic peptides—and imaging to demonstrate elevated filling pressures. Echocardiography remains the cornerstone of non-invasive evaluation, supplemented in selected cases by invasive haemodynamic measurements or diastolic stress testing. Management strategies centre on addressing comorbidities, diuretic control of volume overload and the use of agents proven to reduce hospitalisation and mortality, including sodium-glucose cotransporter 2 inhibitors. Emerging approaches target myocardial fibrosis, endothelial function and skeletal muscle performance. A multidisciplinary, individualised treatment plan can improve exercise capacity, quality of life and long-term outcomes.

Research from Nature Portfolio

Recent work has evaluated multiparametric diagnostic algorithms to refine HFpEF phenotyping and predict exercise intolerance. One study compared two leading scoring systems, demonstrating that both the H2FPEF and HFA-PEFF scores correlate with exercise haemodynamics and reduced peak oxygen uptake. The H2FPEF score showed particular strength in predicting impaired aerobic capacity, while the HFA-PEFF score offered high specificity for intracardiac pressure elevation during exercise. Application of these algorithms in stress echocardiography cohorts increased diagnostic yield from around 10% with simple E/e′ assessment to over 60%, substantially reducing indeterminate results and informing more targeted therapeutic interventions.

Diagnosis and Management of Heart Failure with Preserved Ejection Fraction publication trend

The graph below shows the total number of articles in diagnosis and management of heart failure with preserved ejection fraction across all publications each year (not limited to Nature Index journals).

Technical terms

Heart failure with preserved ejection fraction (HFpEF): clinical syndrome of heart failure symptoms and signs with a left ventricular ejection fraction ≥50%, often associated with diastolic dysfunction.

Ejection fraction (EF): proportion of blood ejected from the left ventricle during systole, expressed as a percentage, with normal values ≥50%.

Natriuretic peptides (NT-proBNP): biomarkers secreted by ventricular myocardium in response to wall stress, used for diagnosis and prognostic stratification in heart failure.

Echocardiography: ultrasound imaging modality that assesses cardiac structure, systolic and diastolic function, and estimates intracardiac pressures non-invasively.

H2FPEF score: diagnostic tool combining six clinical and echocardiographic variables to estimate the probability of HFpEF and predict exercise intolerance.

HFA-PEFF score: comprehensive scoring algorithm endorsed by heart failure associations that integrates functional, structural and biomarker domains to diagnose HFpEF.

References

1. Artificial intelligence methods for improved detection of undiagnosed heart failure with preserved ejection fraction. European Journal of Heart Failure (2024).
2. Automated Echocardiographic Detection of Heart Failure With Preserved Ejection Fraction Using Artificial Intelligence. JACC Advances (2023).
3. The H2FPEF and HFA-PEFF algorithms for predicting exercise intolerance and abnormal hemodynamics in heart failure with preserved ejection fraction. Scientific Reports (2022).
4. Heart failure with preserved ejection fraction: diagnosis, risk assessment, and treatment. Clinical Research in Cardiology (2024).