Heart Failure with Preserved Ejection Fraction
The fifth episode features Geoffrey Mills, MD, PhD, covering heart failure with preserved ejection fraction, including the following topics
- Heart failure with preserved ejection fraction versus heart failure with reduced ejection fraction
- The difference between heart failure with preserved ejection fraction and diastolic dysfunction
- Treatment of heart failure with preserved ejection fraction
Geoffrey Mills, MD, PhD
Assistant Residency Program Director, Assistant Professor
Department of Family and Community Medicine and Department of Physiology
Jefferson Medical College, Philadelphia, PA
Dr. Mills is a graduate of Temple University School of Medicine and did his Family Medicine training at Thomas Jefferson University Hospital in Philadelphia. He has a research background in cardiovascular physiology and has a dual appointment in the Departments of Family and Community Medicine and Department of Physiology at Jefferson Medical College. His teaching and clinical interests relate to cardiovascular disease and preventative medicine and he studies risk communication in primary care.
Joining us today is Geoffrey Mills MD, PhD. Doctor, why did you choose heart failure with preserved ejection fraction as the topic for this month’s podcast?
Physicians are familiar with managing congestive heart failure – common symptoms and treatment approaches – but less familiar with the differences in treatment and management of patients exhibiting symptoms of heart failure, but with preserved left ventricular function. Unfortunately, at this point, there are few large, high-quality trials available to guide treatment decisions in this patient population, so physicians often apply principles most appropriate for patients with reduced ejection fraction. With our aging population, we will be seeing more HF with preserved ejection fraction so physicians should be comfortable identifying this condition.
What is the difference between heart failure with preserved ejection fraction and diastolic heart failure?
HF with preserved ejection fraction is the preferred terminology for diastolic heart failure. There is an important distinction between HFPEF and diastolic dysfunction, which is often a finding on routine echocardiograms. Diastolic dysfunction refers to an abnormality of diastolic compliance, filling or relaxation of the ventricle. This can occur in the absence of symptoms classically associated with heart failure – shortness of breath, fatigue and volume overload. If these signs and symptoms are present in a patient with a normal ejection fraction, they are said to have HFPEF. Usually, you will find some evidence of diastolic dysfunction in these patients as well.
Who is most at risk to develop this condition?
When compared with HFREF, patients with preserved ejection fraction are older, more likely female and usually have a history of hypertension. They are also more likely to have atrial fibrillation but less likely to have a history ischemic disease, although coronary artery disease is a common co-morbidity. They have similar symptoms as those with reduced ejection fraction like reduced exercise capacity and reduced quality of life. In patients presenting with these symptoms, consider HFPEF in your differential diagnoses, especially for older women with a history of long-standing hypertension.
Acute exacerbations of HFPEF cause the classic HF symptoms of fluid overload and chest pain in patients. These flare-ups are most commonly triggered by hypertensive crises but can also be due to tachycardia, especially atrial fibrillation, renal impairment or other acute illnesses.
What is the course of HFPEF?
HFPEF is a chronic disease for most patients with a slow progression and occasional exacerbations. Unfortunately, the presence of diastolic dysfunction by itself is associated with increased risk of cardiovascular events. There is some controversy about whether there is a difference in the mortality rates between patients with HFPEF and HFREF but it is generally accepted that patients with HFPEF who are male, higher NHYA classification, ischemic disease or impaired renal function fare worse than other patients.
HFPEF is a chronic disease and physicians should aim to control hypertension, ventricular rate, fluid balance and, in some patients, consider revascularization. Patients should be instructed in self-care behaviors like daily weights and medication adherence as well as dietary sodium restriction.
How should clinicians approach the treatment of HFPEF?
As I mentioned, the main treatment goals are treating hypertension, maintaining a normal heart rate and keeping the patient euvolemic. The challenge in HFPEF is that there are few clinical trials demonstrating meaningful benefits in morbidity and mortality to guide the choice of pharmacologic agents. For instance, ACE inhibitors and angiotensin receptor blockers can improve diastolic function and may improve functional class and exercise capacity but there is limited data showing improvements in morbidity and mortality. Both are reasonable choices for blood pressure control, especially for patients with LV hypertrophy but they should not be used in combination.
Beta blockers can help in two ways: blood pressure control and heart rate control. Again, evidence for improved morbidity and mortality is lacking, but some trials have suggested benefits for this group of patients. If we project treatment recommendations for patients with reduced ejection fraction, carvedilol, long-acting metoprolol and bisoprolol seem most promising for use in these patients until new data are available.
Calcium channel blockers will also help with hypertension and heart rate in these patients and may, in theory, improve diastolic function. Verapamil has been shown in small studies to improve exercise capacity and HF symptoms in HFPEF.
New trials are looking at the role of aldosterone antagonist therapy in HFPEF with early studies suggesting that they may improve myocardial function. Until more data are available, these drugs are not generally recommended for patients with preserved EF.
Diuretics such as furosemide are used in acute exacerbations to improve fluid overload but may be necessary in some patients to maintain fluid balance chronically.
I hope that we will have some more data to help guide these treatment decisions in this patient population, but until that time, most of our treatment options are drawn from studies in patients with reduced ejection fraction.
How is this different from heart failure with reduced ejection fraction? Are there unique treatment considerations?
One unique difference is that patients with HFPEF seem to tolerate the initiation of beta blockers and calcium channel blockers during acute exacerbations. Patients with systolic HF generally are not started on new beta blockers during acute exacerbations for fear of depressed contractility. So, when heart rate control is needed, these agents can be used, even during acute exacerbations. Another difference is that inotropic agents like digoxin and dobutamine are not indicated for use in acute or chronic HFPEF. Finally, patients who are very sensitive to tachycardia from atrial fibrillation should be considered for rhythm control strategies to maintain sinus rhythm. Guidelines also suggest that coronary revascularization should be considered in patients with CAD and diastolic dysfunction.
Are there particular lifestyle recommendations that patients should follow?
Weight loss, smoking cessation and dietary changes should be discussed with patients to reduce ischemic risk and improve blood pressure control. Dietary sodium restriction to less than 2 grams per day will reduce mean arterial blood pressure and may prevent hypokalemia in patients on diuretics – I would recommend the sodium-restricted DASH diet, which has been shown to reduce blood pressure and improve exercise tolerance in patients with HFPEF.
Most patients should monitor daily weights and have some plan in place for what to do if they begin to gain weight or have symptoms of heart failure. This type of action planning is a good way to engage patients in their medical care and can reduce the risk of hospitalization. In addition, exercise training can improve functional capacity in patients with HFPEF – some areas will have access to cardiac rehabilitation services but most patients can safely participate in moderate intensity aerobic exercise 3-5 times per week.