ABBR: HFpEF Signs and symptoms of heart failure (HF), including dyspnea, orthopnea or nocturnal dyspnea, and radiological evidence of pulmonary congestion, but an ejection fraction that is greater than 45%.

INCIDENCE
HFpEF occurs in high percentage of older adults. It is about twice as likely to occur in women, but both sexes can be affected.

CAUSES
Most patients have a long history of high blood pressure, and many have had atrial fibrillation.

DIAGNOSIS
An echocardiogram is the best test to distinguish heart failure with a preserved ejection fraction from high failure with a reduced ejection fraction (EF). An echocardiographic EF of 45% or higher in a patient with signs and symptoms of heart failure establishes the diagnosis. An EF less than 45% is diagnostic of heart failure with reduced ejection fraction (HFrEF). Other methods to assess ejection fraction, e.g., nuclear imaging of the heart and cardiac catheterization, are also helpful. Blood tests, including a complete blood count, serum chemistries and assessments of B-type natriuretic peptide (BNP), are essential in any HF patient, but they do not distinguish between those patients with reduced or preserved ejection fractions.

SYMPTOMS AND SIGNS
Patients with any form of HF report an inability to exercise or to lie flat in bed due to shortness of breath. Many report paroxysmal nocturnal dyspnea (awakening from sleep severely short of breath and being relieved by sitting up). Physical findings in HF include a rapid resting heart rate, distention of neck veins, pulmonary rales, and cardiac gallops (additional heart sounds: S3 or S4).

PREVENTION
Scrupulous management of hypertension reduces the likelihood of HFpEF in some studies by as much as 50%. In patients with established disease, management of hypertension prevents disease progression. Relative to other classes of drugs, diuretics appear to be the most effective treatment; they are typically combined with medications from other classes, e.g., with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and beta or calcium channel blockers. Regular exercise, avoiding smoking, and a prudent diet in adolescence and adulthood appear to reduce the incidence of HFpEF in later years. A sedentary lifestyle increases the risk.

TREATMENT
Diuretic therapy and vasodilating drugs, like nitrates, are given to the patient with HF who is acutely short of breath. Chronic management of HF patients with preserved ejection fraction includes any antihypertensive agent that helps optimize the patient’s overall clinical status. Patients with atrial fibrillation should have their heart rates controlled. Rhythm control (re-establishment of a normal sinus rhythm) does not demonstrably improve the patient's health.

PATIENT CARE
Patients with HFpEF have a high rate of hospitalization and an increased risk of death from cardiovascular disease. They should be educated about the importance of following prescribed medical therapies. In general these patients should avoid overeating, and excessive sodium in the diet (although sodium restriction has not been proven to reduce exacerbations of the disease). Patients should be educated about the signs and symptoms of disease to report to their clinicians, including increases in shortness of breath, reductions in the ability to walk or exercise, and increases in edema and body weight. Acute weight gain often reflects fluid retention, and most patients should learn to discuss changes in weight of more than a few kilograms with their clinicians. Many patients are given instructions to increase diuretic doses transiently when they experience rapid weight gain and afterwards to resume lower doses when body weight drops or lower extremity edema resolves. Medication dosages may need frequent changes to reflect changes in patient status; these dosing modifications should be explained as routine rather than as evidence of haphazard disease management. Patients with HFpEF who develop poorly tolerated palpitations, chest pain, or loss of consciousness should seek medical care immediately. The mortality risk of patients with HFpEF is approximately 5% annually.
SYN: SEE: diastolic dysfunction; SEE: diastolic heart failure;
SEE: heart failure