What Is Heart Failure? (Part 2/3)

What Is Heart Failure with Preserved Ejection Fraction (HFpEF)?

This is Part 2 in the series “What Is Heart Failure?” In Part 1, we explained what heart failure actually means - that the heart is unable to pump enough blood to meet the body’s needs.

But did you know that about half of all the people with heart failure have a preserved pumping function? So, what does that really mean?

Echcardiography of a heart with HFpEF

When the heart pumps normally - but still fails

When most people hear the term heart failure, they imagine the heart has “stopped” or that it can’t pump properly. However, in HFpEF (Heart Failure with Preserved Ejection Fraction), the heart’s pumping strength, measured as ejection fraction (EF) - is still normal.

The problem lies elsewhere: the heart muscle becomes stiffer and doesn’t relax properly between beats. As a result, it fills with less blood, and even though the “pump” looks normal, less blood is delivered with each beat.

This leads to the same symptoms as other forms of heart failure:

• Shortness of breath, especially during exertion

• Swelling in the legs or ankles

• Fatigue and reduced exercise tolerance

  
  

How common is HFpEF?

HFpEF is very common, particularly among older adults. It is estimated that 7–18% of people over 60 years have this condition.

HFpEF is also more common in women than in men, and the likelihood increases with age, high blood pressure, obesity, and diabetes.

Why does HFpEF develop?

HFpEF usually results from several factors acting together. Common causes and risk factors include:

• High blood pressure

• Obesity and physical inactivity

• Diabetes

• Atrial fibrillation

• Older age

  
  

People with HFpEF often have more than one health condition, which can make it difficult to determine what is causing the symptoms.

How is the diagnosis made?

Diagnosis is usually based on:

1. Echocardiography (ultrasound of the heart) – to assess how the heart fills and pumps.

2. Blood test (NT-proBNP) – to detect signs of heart strain or stress.

In some cases, when the diagnosis is uncertain, more advanced tests may be needed, but these are performed only in specialist centers.

Tools used in diagnosis

To help determine whether a patient has HFpEF, doctors often use scoring systems that estimate the likelihood of the condition.

H₂FPEF Score (Reddy et al., 2018)

A simple system that evaluates six factors:

Factor	Explanation	Points
H – Heavy	Obesity (BMI > 30)	2
H – Hypertension	Use of ≥2 blood pressure medications	1
F – Atrial Fibrillation	Presence of atrial fibrillation	3
P – Pulmonary Hypertension	Elevated pressure in the lungs	1
E – Elderly	Age > 60 years	1
F – Filling Pressure	Elevated filling pressure on echocardiography	1

Interpretation:

• 0–1 points: HFpEF unlikely

• 2–5 points: Possible — further testing recommended

• 6–9 points: HFpEF very likely

  
  

HFA-PEFF Score (ESC, 2019)

A European diagnostic algorithm used mainly in hospitals and research. It evaluates three domains:

1. Cardiac structure – chamber size and wall thickness

2. Cardiac function – how the heart fills and the pressures inside

3. Biomarkers – such as NT-proBNP

   
   

In practice, the H₂FPEF score is often used for initial screening, while HFA-PEFF provides a more detailed diagnostic assessment when needed.

Treatment

Managing HFpEF involves treating both the heart and the underlying conditions that often accompany it. The goal is to relieve symptoms, prevent hospitalizations, and improve quality of life.

Key treatment strategies include:

• Optimal control of blood pressure and diabetes

• Weight reduction and regular physical activity

• Diuretics to reduce swelling and shortness of breath

• SGLT2 inhibitors (e.g., dapagliflozin/Forxiga, empagliflozin/Jardiance) and mineralocorticoid receptor antagonists (MRA) (e.g., spironolactone/Spirix, eplerenone), which have shown benefit in HFpEF

Although research on HFpEF is ongoing, treatment options have improved significantly in recent years.

In summary

HFpEF is a common and important type of heart failure in which the heart pumps normally but fills poorly. It often affects older adults, women in particular, and those with high blood pressure, obesity, or diabetes. With proper diagnosis and treatment, many people can experience better quality of life and fewer symptoms.