Heart Failure With Preserved Ejection Fraction: Do We Really Know What It Is?

Ileana L. Piña, MD, MPH


March 29, 2021

This transcript has been edited for clarity.

Hello. I'm Ileana Piña, professor of medicine at Wayne State and at Central Michigan University. This is my blog. I'm also a heart failure transplant cardiologist, which many of you who have been on this blog know.

I want to talk today about HFpEF. We've had these conversations before about heart failure with preserved ejection fraction. Do we really know what it is? Every day that I hear all of these conflicting stories tells me that we really don't know. Is it the ejection fraction alone or is it a complementary group of other symptoms?

There's a trending thought that maybe we need to divide HFpEF into different phenotypes. There may be the diabetic, obese, older women type; there may be the hypertensive phenotype of years of hypertension, with or without left ventricular hypertrophy; and then one that has so many other comorbidities besides diabetes, maybe with chronic lung disease or renal disease, and the heart is maybe just a bystander.

Let's look at ejection fractions. Recently, the PARAGON-HF trial reported some benefit for the drug sacubitril/valsartan. When you look by ejection fraction — we're seeing this in several other studies — when you get below that 50% that we've been calling mrEF, which is that group whose EF sits maybe between 40% and 45%, or the patients that have recovered from an HFrEF event and are that middle-of-the-road ejection fraction, which in my practice have always behaved like HFrEF...

Maybe true HFpEF doesn't start until the EF is over 50% or maybe even over 60%, where the data from PARAGON-HF were just not there but the drug did seem to benefit another group that was catalogued as HFpEF but the ejection fractions were a bit lower.

What do we know? Well, we know from some trials, for example, that left atrial enlargement may be one of the more consistent findings on an echocardiogram of a patient with HFpEF. We know that the prevalence is higher in older patients, particularly women. We know there's a link with obesity, even though the very obese have been excluded from some trials, as in PARAGON-HF.

We want to keep using the mineralocorticoid receptor antagonists because that is a class IIa recommendation. We do have TOPCAT with some very alluring data, particularly in the Americas, with some problems with the data from the Republic of Georgia and the Russian centers.

I have been using the mineralocorticoid receptor antagonists. I like spironolactone; it's very inexpensive at about 10 cents a tablet. As long as you can closely monitor the potassium and watch the renal function, it can be a very helpful drug, not only as a diuretic but also maybe even as an antifibrotic. These are just some points to consider. Maybe neprilysin can be used as an additional drug now. We'll see what the new guidelines show.

I don't think it's true that everything with EF, say, over 40% is HFpEF. There are some good papers in the literature that link, for example, inflammation, obesity, and diabetes to HFpEF where the heart may, in fact, be an innocent bystander when the patient comes in symptomatic.

Think about that and look at those patients in your own practice, and try to divide them up into those phenotypes. Guess what? The numbers are not going down; we're going to be seeing many more patients with HFpEF now and in the future.

This is Ileana Piña, signing off. Thank you for joining me today.

Ileana L. Piña, MD, MPH, is a heart failure and cardiac transplantation expert. She serves as an advisor/consultant to the FDA's Center for Devices and Radiological Health and has been a volunteer for the American Heart Association since 1982. Originally from Havana, Cuba, she is passionate about enrolling more women and minorities in clinical trials. She also enjoys cooking and taking spin classes.

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