Heart Failure with Preserved Ejection Fraction: Diagnosis and Management

 

Am Fam Physician. 2017 Nov 1;96(9):582-588.

Author disclosure: No relevant financial affiliations.

Heart failure with preserved ejection fraction, also referred to as diastolic heart failure, causes almost one-half of the 5 million cases of heart failure in the United States. It is more common among older patients and women, and results from abnormalities of active ventricular relaxation and passive ventricular compliance, leading to a decline in stroke volume and cardiac output. Heart failure with preserved ejection fraction should be suspected in patients with typical symptoms (e.g., fatigue, weakness, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema) and signs (S3 heart sound, displaced apical pulse, and jugular venous distension) of chronic heart failure. Echocardiographic findings of normal ejection fraction with impaired diastolic function confirm the diagnosis. Measurement of natriuretic peptides is useful in the evaluation of patients with suspected heart failure with preserved ejection fraction in the ambulatory setting. Multiple trials have not found medications to be an effective treatment, except for diuretics. Patients with congestive symptoms should be treated with a diuretic. If hypertension is present, it should be treated according to evidence-based guidelines. Exercise and treatment by multidisciplinary teams may be helpful. Atrial fibrillation should be treated using a rate-control strategy and appropriate anticoagulation. Revascularization should be considered for patients with heart failure with preserved ejection fraction and coronary artery disease. The prognosis is comparable to that of heart failure with reduced ejection fraction and is worsened by higher levels of brain natriuretic peptide, older age, a history of myocardial infarction, and reduced diastolic function.

Heart failure with preserved ejection fraction (HFpEF), also referred to as diastolic heart failure, is characterized by signs and symptoms of heart failure and a left ventricular ejection fraction (LVEF) greater than 50%. Heart failure associated with intermediate reductions in LVEF (40% to 49%) is also commonly grouped into this category.

WHAT IS NEW ON THIS TOPIC: HEART FAILURE WITH PRESERVED EJECTION FRACTION

A systematic review found that jugular venous distention, an S3 heart sound, and displaced apical impulse significantly increased the likelihood of heart failure.

In the absence of hypertension, evidence does not support treating heart failure with preserved ejection fraction with any medication except diuretics. Additionally, trials of angiotensin receptor blockers, digoxin, nitrates, and spironolactone raised concerns about adverse effects.

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Physicians should obtain a brain natriuretic peptide or N-terminal pro–brain natriuretic peptide level for patients with possible heart failure if the diagnosis is uncertain.

C

3, 57, 9, 13

Patients with suspected heart failure should be referred for two-dimensional transthoracic echocardiography to confirm the diagnosis and identify preserved or reduced ejection fraction. This includes those with elevated brain natriuretic peptide levels or physical examination findings suggestive of heart failure, and those who meet the Framingham, MICE (Male, Infarction, Crepitations, Edema), or Netherlands criteria for heart failure.

C

3, 5, 10, 11, 13

Patients with HFpEF who have signs and symptoms of fluid overload should be treated with diuretics.

B

3, 5, 31

Patients with HFpEF should be referred for endurance and resistance training.

B

3, 5, 29

Patients with HFpEF and coronary artery disease who have indications should be offered revascularization.

C

3, 5, 30

Hypertension in patients with HFpEF should be treated according to evidence-based hypertension treatment guidelines.

C

3

The use of nitrates, spironolactone, and angiotensin receptor blockers should be avoided in patients with HFpEF. Digoxin should also be avoided in patients 65 years and older who have HFpEF.

B

18, 23, 25, 27


HFpEF = heart failure with preserved ejection fraction.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Physicians should obtain a brain natriuretic peptide or N-terminal pro–brain natriuretic peptide level for patients with possible heart failure if the diagnosis is uncertain.

C

3, 57, 9, 13

Patients with suspected heart failure should be referred for two-dimensional transthoracic echocardiography to confirm the diagnosis and identify preserved or reduced ejection fraction. This includes those with elevated brain natriuretic peptide levels or physical examination findings suggestive of heart

The Authors

show all author info

JOHN D. GAZEWOOD, MD, MSPH, is director of the residency program and an associate professor in the Department of Family Medicine at the University of Virginia Health System, Charlottesville....

PATRICK L. TURNER, MD, is in private practice in Richmond, Va. At the time the article was written, he was a clinical instructor in the Department of Family Medicine at the University of Virginia Health System.

Address correspondence to John D. Gazewood, MD, MSPH, University of Virginia Health System, P.O. Box 800729, Primary Care Center, 1221 Lee St., Charlottesville, VA 22911 (e-mail: jdg3k@hscmail.mcc.virginia.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Borlaug BA, Paulus WJ. Heart failure with preserved ejection fraction: pathophysiology, diagnosis, and treatment. Eur Heart J. 2011;32(6):670–679....

2. Aurigemma GP, Gaasch WH. Clinical practice. Diastolic heart failure. N Engl J Med. 2004;351(11):1097–1105.

3. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147–e239.

4. Lee DS, Gona P, Vasan RS, et al. Relation of disease pathogenesis and risk factors to heart failure with preserved or reduced ejection fraction: insights from the Framingham Heart Study of the National Heart, Lung, and Blood Institute. Circulation. 2009;119(24):3070–3077.

5. Ponikowoski P, Voors AA, Anker SD, et al.; Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure from the European Society of Cardiology (ESC). 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur J Heart Fail. 2016;18(8):891–975.

6. Madhok V, Falk G, Rogers A, Struthers AD, Sullivan FM, Fahey T. The accuracy of symptoms, signs and diagnostic tests in the diagnosis of left ventricular dysfunction in primary care: a diagnostic accuracy systematic review. BMC Fam Pract. 2008;9:56.

7. Mant J, Doust J, Roalfe A, et al. Systematic review and individual patient data meta-analysis of diagnosis of heart failure, with modelling of implications of different diagnostic strategies in primary care. Health Technol Assess. 2009;13(32):1–207.

8. Martindale JL, Wakai A, Collins SP, et al. Diagnosing acute heart failure in the emergency department: a systematic review and meta-analysis. Acad Emerg Med. 2016;23(3):223–242.

9. Kelder JC, Cowie MR, McDonagh TA, et al. Quantifying the added value of BNP in suspected heart failure in general practice: an individual patient data meta-analysis. Heart. 2011;97(12):959–963.

10. Roalfe AK, Mant J, Doust JA, et al. Development and initial validation of a simple clinical decision tool to predict the presence of heart failure in primary care: the MICE (Male, Infarction, Crepitations, Edema) rule. Eur J Heart Fail. 2012;14(9):1000–1008.

11. Fonseca C, Oliveira AG, Mota T, et al.; EPICA Investigators. Evaluation of the performance and concordance of clinical questionnaires for the diagnosis of heart failure in primary care. Eur J Heart Fail. 2004;6(6):813–820, 821–822.

12. McKee PA, Castelli WP, McNamara PM, Kannel WB. The natural history of congestive heart failure: the Framingham study. N Engl J Med. 1971;285(26):1441–1446.

13. Kelder JC, Cramer MJ, van Wijngaarden J, et al. The diagnostic value of physical examination and additional testing in primary care patients with suspected heart failure. Circulation. 2011;124(25):2865–2873.

14. Vasan RS, Levy D. Defining diastolic heart failure: a call for standardized diagnostic criteria. Circulation. 2000;101(17):2118–2121.

15. Chinnaiyan KM, Alexander D, Maddens M, McCullough PA. Curriculum in cardiology: integrated diagnosis and management of diastolic heart failure. Am Heart J. 2007;153(2):189–200.

16. Yusuf S, Pfeffer MA, Swedberg K, et al.; CHARM Investigators and Committees. Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: the CHARM-Preserved Trial. Lancet. 2003;362(9386):777–781.

17. Massie BM, Carson PE, McMurray JJ, et al.; I-PRESERVE Investigators. Irbesartan in patients with heart failure and preserved ejection fraction. N Engl J Med. 2008;359(23):2456–2467.

18. Heran BS, Musini VM, Bassett K, Taylor RS, Wright JM. Angiotensin receptor blockers for heart failure Cochrane Database Syst Rev. 2012;(4):CD003040.

19. Cleland JG, Tendera M, Adamus J, Freemantle N, Polonski L, Taylor J; PEP-CHF Investigators. The Perindopril in Elderly People with Chronic Heart Failure (PEP-CHF) study. Eur Heart J. 2006;27(19):2338–2345.

20. Flather MD, Shibata MC, Coats AJ, et al.; SENIORS Investigators. Randomized trial to determine the effect of nebivolol on mortality and cardiovascular hospital admission in elderly patients with heart failure (SENIORS). Eur Heart J. 2005;26(3):215–225.

21. van Veldhuisen DJ, Cohen-Solal A, Böhm M, et al.; SENIORS Investigators. Beta-blockade with nebivolol in elderly heart failure patients with impaired and preserved left ventricular ejection fraction: data from SENIORS (Study of Effects of Nebivolol Intervention on Outcomes and Rehospitalization in Seniors with Heart Failure). J Am Coll Cardiol. 2009;53(23):2150–2158.

22. Yamamoto K, Origasa H, Hori M; J-DHF Investigators. Effects of carvedilol on heart failure with preserved ejection fraction: the Japanese Diastolic Heart Failure Study (J-DHF). Eur J Heart Fail. 2013;15(1):110–118.

23. Edelmann F, Wachter R, Schmidt AG, et al.; Aldo-DHF Investigators. Effect of spironolactone on diastolic function and exercise capacity in patients with heart failure with preserved ejection fraction: the Aldo-DHF randomized controlled trial. JAMA. 2013;309(8):781–791.

24. Pitt B, Pfeffer MA, Assmann SF, et al.; TOPCAT Investigators. Spironolactone for heart failure with preserved ejection fraction. N Engl J Med. 2014;370(15):1383–1392.

25. Redfield MM, Anstrom KJ, Levine JA, et al.; NHLBI Heart Failure Clinical Research Network. Isosorbide mononitrate in heart failure with preserved ejection fraction. N Engl J Med. 2015;373(24):2314–2324.

26. Ahmed A, Rich MW, Fleg JL, et al. Effects of digoxin on morbidity and mortality in diastolic heart failure: the ancillary digitalis investigation group trial. Circulation. 2006;114(5):397–403.

27. Hashim T, Elbaz S, Patel K, et al. Digoxin and 30-day all-cause hospital admission in older patients with chronic diastolic heart failure. Am J Med. 2014;127(2):132–139.

28. Redfield MM, Chen HH, Borlaug BA, et al.; RELAX Trial. Effect of phosphodiesterase-5 inhibition on exercise capacity and clinical status in heart failure with preserved ejection fraction: a randomized clinical trial. JAMA. 2013;309(12):1268–1277.

29. Fukuta H, Goto T, Wakami K, Ohte N. Effects of drug and exercise intervention on functional capacity and quality of life in heart failure with preserved ejection fraction: a meta-analysis of randomized controlled trials. Eur J Prev Cardiol. 2016;23(1):78–85.

30. Hwang SJ, Melenovsky V, Borlaug BA. Implications of coronary artery disease in heart failure with preserved ejection fraction. J Am Coll Cardiol. 2014;63(25 pt A):2817–2827.

31. Faris RF, Flather M, Purcell H, Poole-Wilson PA, Coats AJ. Diuretics for heart failure Cochrane Database Syst Rev. 2012;(2):CD003838.

32. Kane GC, Karon BL, Mahoney DW, et al. Progression of left ventricular diastolic dysfunction and risk of heart failure. JAMA. 2011;306(8):856–863.

33. Pérez de Isla L, Cañadas V, Contreras L, et al. Diastolic heart failure in the elderly: in-hospital and long-term outcome after the first episode. Int J Cardiol. 2009;134(2):265–270.

34. Gerber Y, Weston SA, Redfield MM, et al. A contemporary appraisal of the heart failure epidemic in Olmsted County, Minnesota, 2000 to 2010. JAMA Intern Med. 2015;175(6):996–1004.

35. Tribouilloy C, Rusinaru D, Mahjoub H, et al. Prognosis of heart failure with preserved ejection fraction: a 5 year prospective population-based study. Eur Heart J. 2008;29(3):339–347.

36. Komajda M, Carson PE, Hetzel S, et al. Factors associated with outcome in heart failure with preserved ejection fraction: findings from the Irbesartan in Heart Failure with Preserved Ejection Fraction Study (I-PRESERVE). Circ Heart Fail. 2011;4(1):27–35.

37. Burke MA, Katz DH, Beussink L, et al. Prognostic importance of pathophysiologic markers in patients with heart failure and preserved ejection fraction. Circ Heart Fail. 2014;7(2):288–299.

38. Cleland JG, Taylor J, Freemantle N, Goode KM, Rigby AS, Tendera M. Relationship between plasma concentrations of N-terminal pro brain natriuretic peptide and the characteristics and outcome of patients with a clinical diagnosis of diastolic heart failure: a report from the PEP-CHF study. Eur J Heart Fail. 2012;14(5):487–494.

39. King M, Kingery J, Casey B. Diagnosis and evaluation of heart failure. Am Fam Physician. 2012;85(12):1161–1168.

40. Satpathy C, Mishra TK, Satpathy R, Satpathy HK, Barone E. Diagnosis and management of diastolic dysfunction and heart failure [published correction appears in Am Fam Physician. 2008;78(4):434]. Am Fam Physician. 2006;73(5):841–846.

41. Gutierrez C, Blanchard DG. Diastolic heart failure: challenges of diagnosis and treatment. Am Fam Physician. 2004;69(11):2609–2616.

 

 

Copyright © 2017 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Nov 15, 2017

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article