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.

Performed By:

Andrew JS Coats

Andrew JS Coats

Educational Objectives

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

Target Audience

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

Faculty Biographies

Andrew JS Coats

Andrew JS Coats

Personal History6

Professor Andrew Justin Stewart Coats was born in Melbourne, Australia on 1 February 1958. His father was a Professor of Resuscitation who first described essential fatty acids.

He is an Australian-British academic cardiologist as well as a successful fundraiser, university administrator and inventor. 


Academic History

Professor Coats attended Melbourne Grammar School and studied at Oxford and Cambridge.9 He has higher doctorates from Oxford (DM) and Imperial (DSc.) and an MBA from London Business School.1 

He obtained a Bachelor of Arts in 1979, a Bachelor of Medicine and Surgery in 1981, a Master of Arts in 1982, a PhD in Management in 1989, became a Doctor of Sciences in 1999 and completed a further Masters in Business Administration in 2001.

He is a Diplomate and Fellow of the Australian Institute of Company Directors and a member of the UK Institute of Directors.1 Professor Coats’ research interests are chronic heart failure, hypertension and organizational behaviour. 

His research has greatly influenced the treatment for chronic heart failure, promoting exercise training instead of bed rest. He was instrumental in describing the "muscle hypothesis" of heart failure. This research turned established teaching on its head and promoted exercise training (rather than bed rest) as a treatment for chronic heart failure.3


Career Overview

After completing his medical degree in 1981, Andrew Coats began his career at St Vincent's Hospital, Melbourne. Ten years later, he was appointed Senior Lecturer, supported by the British Heart Foundation, at the National Heart and Lung Institute (NHLI). He was appointed Viscount Royston Professor of Cardiology at Imperial College in 1996 and Director of Cardiology and Associate Medical Director of the Royal Brompton and Harefield NHS trust.9 He was also an honorary consultant physician, Clinical Director for Cardiology and Associate Medical Director at the Royal Brompton Hospital in London.

Professor Coats was appointed Dean of Medicine at the University of Sydney in 2002 and subsequently Deputy Vice-Chancellor.4 Professor Coats was CEO of Norwich Research Park, the UK's oldest and largest research and innovation park. In 2009, Professor Coats was appointed the second Norwich Research Park Professor-at-Large. Concurrently, he was Visiting Professor of Medicine at The University of Sydney in Australia, Consulting Professor for Research Strategy at the Chinese University of Hong Kong and a Guest Scientist at the Charité Medical School of Humboldt University in Berlin.8

In 2017, he was appointed an Officer of the Order of Australia for distinguished service to medical research and tertiary education in the field of cardiology, as an academic and author and as a mentor and role model for young scientists.10 

He was the chair of Australia's peak policy body for Health Informatics, the Australian Health Information Council, the New South Wales Ministerial Advisory Committee on Health and Medical Research (MACMHR) and has been on various committees.4 Professor Coats has published two theses, 15 Government reports, 10 textbooks, two Cochrane reviews, over 500 peer-reviewed full papers and has more than 49,000 career citations.5

Professor Coats has both chaired and been a committee member of many large-scale international drug trials that have influenced the treatment of cardiovascular diseases such as the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) Trial, OPTIMAAL (angiotensin receptor antagonist in heart failure) and SENIORS (management of heart failure in the elderly).

He has been a board director of a number of private and public companies such as Myotec, PsiOxus, Lone Star Heart Inc, Centenary Institute, the Heart Research Institute, Cardiodirect (UK) Limited, the Woolcock Institute of Medical Research and the George Institute of International Health. He was also Editor-in-Chief of the International Journal of Cardiology for nearly 20 years.

Presently, Professor Coats is serving as Joint Academic Vice-President of Monash University, Australia and the University of Warwick, UK. He is President of the Heart Failure Association of the European Society of Cardiology and is Editor-in-Chief of Cardiac Failure Review.


Career Timeline

  • 1991: Senior Lecturer, National Heart and Lung Institute
  • 1996 - 2002: Viscount Royston Professor of Cardiology, Imperial College London
  • 1998 - 2000: Director of Cardiology, Royal Brompton Hospital
  • 1999 - 2015: Editor-in-Chief, International Journal of Cardiology
  • 2000 - 2002: Associate Medical Director, Royal Brompton Hospital
  • 2002 - 2006: Dean of Medicine, University of Sydney
  • 2006 - 2010: Deputy Vice-Chancellor, University of Sydney
  • 2009: Second Norwich Research Park Professor-at-Large
  • 2009 - 2010: Director, Cardiodirect
  • 2010 - 2012: The Norwich Research Park Professor and Chief Executive, NRP and UEA
  • 2011 - 2012: CEO, Norwich Research Park
  • 2011 - 2017: Director, Lone Star Heart Inc.
  • 2013 - 2016: Academic Vice-President (Monash/Warwick Alliance), Monash University
  • 2020 - Present: President, Heart Failure Association
  • 2020 - Present: President-Elect, Presidential Trio of the Heart Failure Association of the ESC
  • Present: Editor-in-Chief, Cardiac Failure Review



  • 1998: Linacre Medal of the Royal College of Physicians 
  • 1999: The Inaugural Michael L Pollock Award, American Heart Association 
  • 2010: Gold Heart Award, American Heart Association
  • 2017: Officer of the Order Of Australia


Areas of Speciality1

  • Chronic heart failure
  • Hypertension
  • Organizational behaviour



  1. https://www.radcliffecardiology.com/authors/andrew-js-coats 
  2. https://en.wikipedia.org/wiki/Andrew_Stewart_Coats#Early_life_and_education 
  3. https://www.radcliffe-group.com/our-team/
  4. https://web.archive.org/web/20110217131215/http://www.msmr.nsw.gov.au/__data/page/21/NSW_Research_-_A_Prescription_for_Health.pdf
  5. https://www.monash.edu/about/structure/senior-staff/andrew-coats 
  6. https://peoplepill.com/people/andrew-coats-1
  7. https://esc365.escardio.org/Person/34057-prof-coats-andrew 
  8. https://warwick.ac.uk/newsandevents/pressreleases/joint_vice-president_announced/ 
  9. https://www.monash.edu/news/articles/professor-andrew-coats-appointed-officer-of-the-order-of-australia
  10. https://www.gg.gov.au/sites/default/files/2019-12/ao_final_media_notes.pdf 


Prof Coats is Editor-in-Chief of the Cardiac Failure Review editorial board. 



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Key References

1. 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]

2. 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

3. 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

4. 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

5. 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