The Management of Heart Failure with Preserved Ejection Fraction
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
- The epidemiology of HFpEF
- The clinical trials in HFpEF
- Why we have not improved prognosis in HFpEF despite many improvements in HFrEF
- Cardiologists in training
- General practitioners with an interest in cardiology
- Age care physicians
Andrew JS Coats
Prof Coats is Editor-in-Chief of the Cardiac Failure Review journal. He has published over 20 patents, more than 750 full research papers and more than 120,000 career citations and has a personal H-index of 146. Andrew was elected to the Presidential Trio of the Heart Failure Association of the ESC in 2018 and will serve as its president from 2020-2022.
Prof Coats is the Immediate past-President of the Heart Failure Association and past-Professor of Cardiology at the University of Warwick, UK. He has also held posts as Head of Cardiology at Imperial College, London and Associate Medical Director and Director of Cardiology at the Royal Brompton and Harefield Hospitals, London. From 2012 to 2017 he was Director of the Monash-Warwick Alliance, and before that served as Deputy Vice-Chancellor and Dean of Medicine at the University of Sydney.
He is an Australian-British academic cardiologist as well as a successful fundraiser, university administrator and inventor. Prof Coats' main interest is heart failure and his current position is Scientific Director at the Heart Institute, Australia.
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