Heart Failure with Preserved

Ejection Fraction (HFpEF)

Erwinanto MD

The Indonesian Heart Association Working

Group on Heart Failure

HFpEF: What’s in a Name?
 Evidence of pulmonary congestion despite
normal cardiac output at rest

Control HFpEF
Resting hemodynamic P-value
(n=73) (n=109)

Cardiac output (L/min) 5.4 ± 1.4 5.4 ± 1.7 0.9

Cardiac index (L/min/m2) 2.8 ± 0.7 2.6 ± 0.8 0.2

PCWP (mmHg) 9±3 16 ± 6 <0.0001

Abudiab MM, et al. Eur J Heart Fail 2013;15:776-785

 FORRESTER CLASSIFICATION
3.5
Normal
3
HFpEF
2.5 H-I H-II
CI (L/m/m2)

C-I C-II
2.2
Hypoperfusion

2 H-III H-IV
C-III C-IV
1.5 Fluid administration

Mortality 22.4% HFrEF

1

Hypovolemic shock
0.5
0 5 10 15 20 25 30 35 40
18
PCWP (mm Hg)

Hypovolemia Pulmonary congestion

Adapted from Forester et al. Am J Cardiol 1977;39:137

 Impaired cardiac output reserve

Control HFpEF
Peak exercise hemodynamic P-value
(n=73) (n=109)

Cardiac output (L/min) 12.5 ± 2.8 9.2 ± 2.8 <0.0001

Cardiac index (L/min/m2) 6.4 ± 1.3 4.4 ± 1.2 <0.0001

PCWP (mmHg) 14 ± 4 33 ± 8 <0.0001

Abudiab MM, et al. Eur J Heart Fail 2013;15:776-785

Chronotropic incompetence causes
impaired cardiac output reserve

Abudiab MM, et al. Eur J Heart Fail 2013;15:776-785

 Less increase of EF during exercise

Ejection fraction (%)

At rest P-value

Control 63 ± 8
0.09
HFpEF 65 ± 7

Abudiab MM, et al. Eur J Heart Fail 2013;15:776-785

 Afterload

Katup aorta
menutup
Katup aorta
Ejeksi terbuka
Tekanan ventrikel

Relaksasi Kontraksi

Preload

Katup mitral Pengisian

terbuka Katup mitral
menutup

Volume ventrikel
Resting LV Pressure-Volume Loops in Systolic and
Diastolic Dysfunction

Afterload

Normal Increased Normal Normal

Preload

Aurigemma GP, Gaasch WH. N Engl J Med 2004;351:1097-1105

Mechanism of HFpEF
 Molecular Basis of Heart Failure

Myocardial injury

↑myocyte size
Activation of Hypertrophic
signaling pathways response
↑extra cellular
matrix

Impaired myocyte function

Heart failure
Myocyte loss
Sharma K, Kass DA. Circ Res. 2014;115:79-96
Sharma K, Kass DA. Circ Res. 2014;115:79-96
Diagnosis of HFpEF
 Terminology of heart failure with preserved (HFpEF), mid-range (HFmrEF)

and reduced ejection fraction (HFrEF)

Type of HF HFrEF HFmrEF HFpEF

1 Symptoms ± signs Symptoms ± signs Symptoms ± signs

2 LVEF ˂40% LVEF 40-49% LVEF ≥50%

CRITERIA

1. ↑Natriuretic peptide 1. ↑Natriuretic peptide

2. At least 1 additional 2. At least 1 additional

3 ̶
criterion: criterion:
a) LVH and/or LAE a) LVH and/or LAE
b) diastolic dysfunction b) diastolic dysfunction

LVEF = left ventricular ejection fraction; LVH = left ventricular hypertrophy; LAE = left atrial enlargement

Ponikowski P, et al. Eur Heart J doi:10.1093/eurheartj/ehw128

• May be higher in AF and elderly without heart failure
• May be normal in obese patients with HFpEF

Ponikowski P, et al. Eur Heart J doi:10.1093/eurheartj/ehw128

Bishu K, et al. Am Heart J 2012; 164:763-770
Key structural and functional alteration in HFpEF

Left atrial volume index (LAVI)* ˃ 34 mL/m2

≥ 115 g/m2 (males)

Left ventricular mass index (LVMI)
≥ 95 g/m2 (females)

E/é ≥ 13

Mean é septal and lateral wall < 9 cm/s

*LAVI is increased by AF

Ponikowski P, et al. Eur Heart J doi:10.1093/eurheartj/ehw128

 Invasive hemodynamics at rest

Pulmonary capillary wedge pressure

≥ 15 mm Hg
(PCWP)

Left ventricular end diastolic pressure

≥ 16 mm Hg
(LVEDP)

Ponikowski P, et al. Eur Heart J doi:10.1093/eurheartj/ehw128

Treatment of HFpEF
Clinicians should recommend a

daily target of 30 minutes of

aerobic exercise.

Redfield MM. N Engl J Med 2016;375:1868-77.

Drug treatment effects on outcomes in HFpEF:
a systematic review and meta-analysis

Zheng SL, et al. Heart 2017;0:1–9. doi:10.1136/heartjnl-2017-311652

 Solomon SD, et al. J Am Coll Cardiol HF 2017;5:471–82

PARAGON-HF will determine whether sacubitril/valsartan

is superior to angiotensin receptor blockade alone in

patients with chronic symptomatic HFpEF.

Recommendations for treatment of patients with HFpEF

Ponikowski P, et al. Eur Heart J doi:10.1093/eurheartj/ehw128

 Clinical
Phenotypes
and
Comorbid
Conditions
of HFpEF

Samson R, et al.
J Am Heart Assoc 2016
doi: 10.1161/JAHA.115.002477
Take-home message
• Heart failure with preserved ejection fraction remains

among the most challenging of clinical syndromes for

the practicing clinician and scientist alike.

• The diagnosis of chronic HFpEF, especially in the

typical elderly patient with co-morbidities and no

obvious signs of central fluid overload, is

cumbersome and a validated gold standard is

missing.
• Medications that improve outcomes in patients who
have heart failure with a reduced ejection fraction
have not been shown to be of benefit in those who
have heart failure with a preserved ejection fraction.

• Treatment of heart failure with a preserved ejection

fraction should include diuretics for volume
overload, treatment for cardiovascular and
noncardiovascular coexisting conditions, and
aerobic exercise training to increase exercise
tolerance.