The Management of Heart Failure with Preserved Ejection Fraction

Webinar - The Management of Heart Failure with Preserved Ejection Fraction

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Heart failure is defined as a clinical syndrome and is known to present with a number of different pathophysiological patterns. There is a remarkable degree of variation in measures of left ventricular systolic emptying and this has been used to categorise heart failure into two separate types: low ejection fraction (EF) heart failure or HF-REF and high EF heart failure or HF-PEF. Here we review the pathophysiology, epidemiology and management of HF-PEF and argue that sharp separation of heart failure into two forms is misguided and illogical, and the present scarcity of clinical trial evidence for effective treatment for HF-PEF is a problem of our own making; we should never have excluded patients from major trials on the basis of EF in the first place. Whilst as many heart failure patients have preserved EFs as reduced, we have dramatically under-represented HF-PEF patients in trials. Only four trials have been performed in HF-PEF specifically, and another two trials that recruited both HF-PEF and HF-REF can be considered. When we consider the similarity in outcomes and neurohormonal activation between HF-REF and HF-REF, the vast corpus of trial data that we have to attest to the efficacy of various treatment (angiotensin-converting-enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], beta-blockers and aldosterone antagonists) in HF-REF, and the much more limited number of trials of similar agents showing near statistically significant benefits in HF-PEF the time has come rethink our management of HF-PEF, and in particular our selection of patients for trials.


Andrew JS Coats is the inaugural Joint Academic Vice-President of Monash University, Australia and the University of Warwick, UK and Director of the Monash-Warwick Alliance. He was head of Cardiology at the Royal Brompton Hospital and Imperial College London and a former Dean of Medicine at the University of Sydney. He has been Editor-in-Chief of the International Journal of Cardiology since 1999.

Additional information on Wikipedia:

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Target Audience

  • Cardiologists
  • Cardiologists in training
  • General practitioners with an interest in cardiology
  • Age care physicians

Learning Objectives

This webinar is to inform and educate interventional cardiologists and cardiac surgeons on:

  • The epidemiology of HFpEF
  • The clinical trials in HFpEF
  • Why we have not improved prognosis in HFpEF despite many improvements in HFrEF

Key references:

  • Senni M1, Gavazzi A1, Oliva F2, Mortara A3, Urso R4, Pozzoli M5, Metra M6, Lucci D4, Gonzini L4, Cirrincione V7, Montagna L8, Di Lenarda A9, Maggioni AP10, Tavazzi L5; On the behalf of the IN HF Outcome Investigators. In-hospital and 1-year outcomes of acute heart failure patients according to presentation (de novo vs. worsening) and ejection fraction. Results from IN-HF Outcome Registry. Int J Cardiol. 2014 Feb 22. pii: S0167-5273(14)00371-4. doi: 10.1016/j.ijcard.2014.02.018. [Epub ahead of print]
  • Campbell RT. Jhund PS. Castagno D. Hawkins NM. Petrie MC. McMurray JJ. What have we learned about patients with heart failure and preserved ejection fraction from DIG-PEF, CHARM-preserved, and I-PRESERVE?. [Review] Journal of the American College of Cardiology. 60(23):2349-56
  • Flather MD, Shibata MC, Coats AJ, Van Veldhuisen DJ, Parkhomenko A, Borbola J, Cohen-Solal A, Dumitrascu D, Ferrari R, Lechat P, Soler-Soler J, Tavazzi L, Spinarova L, Toman J, Böhm M, Anker SD, Thompson SG, Poole-Wilson PA; 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 Feb;26(3):215-25
  • 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 Oct;27(19):2338-45
  • Yusuf S, Pfeffer MA, Swedberg K, Granger CB, Held P, McMurray JJ, Michelson EL, Olofsson B, Ostergren J; 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 Sep 6;362(9386):777-81

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