Management of patients with heart failure and preserved ejection fraction

The pathophysiology of HFpEF is complex, and systemic changes related to various comorbid conditions drive myocardial dysfunction in myriad differing ways. The diagnosis of HFpEF can seem complex, but recent guidelines recommend use of a simple three-step diagnostic pathway to enable effective diagnosis in the majority of cases. For patients whose initial testing is inconclusive, referral to specialist centres for additional exercise testing should be considered. Regardless of LVEF, a diagnosis of HF has significant negative effects on both the quality and quantity of life. HFpEF represents 50% of all HF cases, and these patients are currently recognised as having the greatest unmet need in cardiology, with many HF services not offering care to this patient group. Due to an ageing population and increasing prevalence of comorbidities, HFpEF incidence is rising. Outcomes in HFpEF are comparable with those in HFrEF; therefore, intervention should be implemented early to prevent mortality, morbidity and poor patient reported outcomes. HFpEF is associated with multimorbidity, with as many as 50% of patients having five or more significant comorbidities. Management of the comorbidities and diuretic therapy have long been central in the treatment of HFpEF with the aim of reducing symptom burden and preventing hospitalisation, but without clinical trial data in support of this. However, breakthrough RCT data on SGLT2 inhibitor use in HFpEF (in particular EMPEROR-Preserved and DELIVER) show improved patient-reported outcomes, and reduction in the primary endpoint of heart failure hospitalisations and CV death. SGLT2 inhibitor therapy for HFpEF has been given a class 2 a recommendation in the 2022 AHA HF guidelines, and we would expect an update in future European HF guidelines and NICE clinical guidance. © 2023 Authors. All rights reserved.