Heart failure with preserved ejection fraction: current understanding and emerging concepts

Heart failure is a major health problem with significant morbidity and mortality. Although impressive advances in treatment and reduction in mortality have marked heart failure with reduced ejection fraction (HFrEF), the mortality in patients with heart failure with preserved ejection fraction (HFpEF), which accounts for nearly half of heart failure cases, has remained unchanged. This may be because of the lack of consistent diagnostic criteria and limited understanding of the pathophysiology of HFpEF, and thus appropriate treatment options.

Recent data suggest that HFpEF consists of multiple abnormalities rather than a distinct entity. Advances in testing have improved diagnosis, but further validation is required. The discoveries of new pathological abnormalities have identified potential new drug therapy targets. Traditional agents with strong evidence in HFrEF have proved unsuccessful in HFpEF. Newer agents such as angiotensin receptor neprilysin inhibitor, sildenafil, and ivabradine have demonstrated benefits without improving mortality. Lastly, as HFpEF patients are older with more comorbidities, alternate endpoints to survival benefit should be considered.

Although enormous strides have been made in understanding the pathophysiology and refining the diagnostic criteria of HFpEF, there is currently no pharmacological therapy with mortality benefits. Further characterization and the recruitment of more homogeneous patient populations will be essential to identify effective treatments.