Article Impact Level: HIGH Data Quality: STRONG Summary of Journal of the American College of Cardiology, 81(18), 1810–1834. https://doi.org/10.1016/j.jacc.2023.01.049 Dr. Barry Borlaug et al.
Points
- Heart failure with preserved ejection fraction (HFpEF) is rising due to aging, obesity, and cardiometabolic disorders. However, it remains under-recognized in everyday practice despite advancements in understanding and diagnosis.
- HFpEF has a higher incidence and prevalence than heart failure with reduced ejection fraction (HFrEF), and its risk factors include obesity, metabolic dysfunction, and physical inactivity.
- Survival rates for HFpEF are similarly poor compared to HFrEF, with high mortality rates reported among patients with HFpEF.
- Common disease mechanisms for HFpEF involve diastolic dysfunction, hypertensive left ventricular remodeling, abnormal ventricular-arterial coupling, and chronotropic incompetence, although recent research has expanded the understanding of these mechanisms.
- Diagnosis of HFpEF relies on symptoms, objective evidence of congestion, and an ejection fraction of 50% or higher, and once diagnosed, a systematic approach to treatment is crucial, including management of comorbidities and implementation of pharmacologic and nonpharmacologic therapies.
Summary
Heart failure with preserved ejection fraction (HFpEF) is a growing concern due to its rising incidence and prevalence, primarily driven by aging, obesity, sedentariness, and cardiometabolic disorders. Although recent advancements have shed light on the underlying pathophysiology and facilitated more straightforward diagnosis, HFpEF remains under-recognized in clinical practice.
This is problematic considering the emergence of highly effective pharmacologic and lifestyle-based treatments that can improve patient outcomes. To address these issues, researchers emphasize the importance of precise phenotyping based on pathophysiological characteristics to enhance patient characterization and individualized treatment. This research paper provides a comprehensive analysis of HFpEF epidemiology, pathophysiology, diagnosis, and treatment.
Data reveals that while the overall incidence of heart failure (HF) in the United States seems stable or decreasing, the incidence of HFpEF continues to rise. The prevalence of HFpEF is also increasing, and it is projected to surpass that of HF with reduced ejection fraction (HFrEF). Several risk factors, including older age, hypertension, ischemic heart disease, obesity, metabolic dysfunction, and physical inactivity, are associated with HFpEF, with obesity and metabolic dysfunction showing a stronger predisposition towards HFpEF. Survival rates for HFpEF are equally poor compared to HFrEF, with high mortality rates reported among individuals with HFpEF.
Various hypotheses have been proposed to explain the common disease mechanisms underlying HFpEF. Initially, diastolic dysfunction resulting from hypertensive left ventricular remodeling was considered the primary cause, aggravated by abnormal ventricular-arterial coupling and chronotropic incompetence. However, recent years have seen an evolution in these mechanisms, incorporating a broader range of contributing factors. The diagnosis of HFpEF relies on a combination of patient history, symptoms such as dyspnea and fatigue, objective evidence of congestion, and an ejection fraction of 50% or higher. Physical examination findings may not always indicate congestion, necessitating additional diagnostic measures such as plasma NP levels.
Once diagnosed and other potential causes have been ruled out, a systematic approach to HFpEF treatment is crucial, involving the management of comorbidities and the implementation of pharmacologic and nonpharmacologic therapies. While significant progress has been made in understanding HFpEF over the past two decades, knowledge gaps and unmet needs persist. The increasing prevalence of HFpEF, underdiagnosis, poor prognosis, limited therapeutic options, and substantial healthcare burden underscore the urgency for improved diagnostic and therapeutic strategies. However, recent successes with SGLT2i therapy have demonstrated the treatability of HFpEF, and ongoing research endeavors are bridging the gap between clinical observations and molecular mechanisms, offering hope for future advancements in the field.
Link to the article: https://www.sciencedirect.com/science/article/abs/pii/S0735109723050210
References Borlaug, B. A., Sharma, K., Shah, S. J., & Ho, J. E. (2023). Heart failure with preserved ejection fraction. Journal of the American College of Cardiology, 81(18), 1810–1834. https://doi.org/10.1016/j.jacc.2023.01.049
