Heart failure with preserved ejection fraction

Overview

Heart failure with preserved ejection fraction (HFpEF) is a condition where the heart's main pumping chamber (the left ventricle) becomes stiff and cannot relax properly. This means it doesn't fill with enough blood between beats, even though the squeezing function (ejection fraction) is normal. As a result, less blood is pumped to the body, causing symptoms like shortness of breath and fatigue.

Yes, HFpEF accounts for about 50% of all heart failure cases. It is becoming more common as the population ages and rates of conditions like high blood pressure and diabetes increase.

HFpEF is more common in older adults, especially women over 65. It also affects people with long-standing high blood pressure, diabetes, obesity, and those who have had a heart attack or other heart problems.

Symptoms

Common symptoms

• Shortness of breath during activity or when lying down
• Feeling very tired or weak
• Swelling in the ankles, feet, legs, or abdomen
• Rapid or irregular heartbeat
• Persistent cough or wheezing, especially when active

Symptoms in children

• Heart failure with preserved ejection fraction is rare in children, but when it occurs, symptoms include poor feeding, slow growth, being unusually sleepy or irritable, and rapid breathing.

Symptoms in older adults

• In older adults, symptoms like shortness of breath and fatigue may be mistaken for normal aging. New confusion or difficulty with daily activities can also occur.

Causes

Main causes

• High blood pressure (hypertension) that makes the heart muscle stiff over time
• Coronary artery disease (narrowing of the heart's blood vessels)
• Diabetes, which can damage heart muscle and blood vessels
• Obesity, which increases the workload on the heart
• Aging – the heart naturally becomes stiffer with age

Risk factors

• Being over 65 years old
• Being female
• Having high blood pressure, diabetes, or obesity
• Having a history of heart attack or heart valve disease
• Sleep apnea
• Kidney disease

When to see a doctor

See a doctor urgently if:

• If you have any emergency symptoms like severe shortness of breath or chest pain, call your local emergency number immediately.
• If you notice new or worsening swelling, rapid weight gain, or a fast heartbeat, see a doctor the same day.

Book a routine appointment if:

• If you have mild symptoms like occasional tiredness or slight swelling that comes and goes, schedule an appointment with your primary care provider or a heart specialist (cardiologist).
• If you have been diagnosed with conditions that increase your risk (high blood pressure, diabetes), have regular check-ups to manage them.

Diagnosis

A doctor diagnoses HFpEF by taking your medical history, doing a physical exam, and ordering tests to see how your heart is working. They look for signs that the heart is stiff and not filling properly, while still having a normal pumping ability.

Tests that may be done

• Echocardiogram (ultrasound of the heart) – measures the stiffness and filling pressure of the heart
• Blood tests – check for conditions like anemia, kidney problems, or a chemical called BNP that rises in heart failure
• Chest X-ray – looks for fluid in the lungs or an enlarged heart
• Electrocardiogram (ECG) – records the heart's electrical activity
• Stress test – shows how your heart performs during activity

What to expect at your appointment

If you are having symptoms, your doctor may refer you to a heart specialist. You will likely need multiple appointments and tests to confirm the diagnosis. The process can take a few weeks, but it is important for getting the right treatment.

Treatment

HFpEF is treated by managing the underlying causes and relieving symptoms. Treatment focuses on reducing fluid buildup, controlling blood pressure, and improving the heart's ability to relax. Most people need a combination of lifestyle changes and medicines. In some cases, procedures or surgery may be needed for related heart problems.

Self-care at home

• Limit salt (sodium) in your diet to reduce fluid retention
• Weigh yourself daily at the same time and report any sudden weight gain to your doctor
• Stay as active as your doctor recommends – a gentle walking program can help
• Monitor and control your blood pressure, blood sugar (if diabetic), and cholesterol
• Avoid alcohol and tobacco

Medical treatments

Doctors prescribe medicines to help your body get rid of extra fluid (diuretics), relax blood vessels, and manage high blood pressure, diabetes, or rhythm problems. Some newer medicines may also help improve how well the heart relaxes. Treatment plans are personalized, and your doctor will work with you to find what works best.

When is surgery considered?

Surgery is not usually needed for HFpEF itself. However, if you also have a narrowed heart valve or blocked coronary arteries, surgery (like valve repair or bypass) may be recommended. Your doctor will discuss the options with you.

Living with this condition

Living with HFpEF means paying attention to your body. You may need to rest more, avoid heavy physical activity, and plan your day to conserve energy. It is important to take your medicines exactly as prescribed and keep all appointments with your healthcare team.

Lifestyle tips

• Eat a heart-healthy diet low in salt, saturated fat, and added sugars
• Stay physically active within your limits – check with your doctor before starting any new exercise
• Monitor your weight daily and keep a log to share with your doctor
• Get enough sleep and manage stress with relaxation techniques or talking to a counselor
• Avoid smoking and limit alcohol

Diet and exercise

A diet rich in fruits, vegetables, whole grains, and lean protein (like fish or poultry) can help control blood pressure and fluid levels. Limit processed foods and salty snacks. For exercise, gentle activities like walking, cycling, or water aerobics are often safe. Your doctor or a cardiac rehabilitation specialist can design a program just for you.

Mental health and emotional wellbeing

Living with a chronic condition like HFpEF can cause worry, sadness, or frustration. It is normal to feel anxious about your health. Talk to your doctor if these feelings persist – they can connect you with a counselor or support group. Remember, your mental health is just as important as your physical health.

Prevention

You cannot always prevent HFpEF, but you can lower your risk by keeping your blood pressure, blood sugar, and weight in a healthy range. Eating well, staying active, not smoking, and limiting alcohol all help protect your heart.

Vaccines

Getting vaccinated against the flu and pneumonia is important because infections can worsen heart failure. Ask your doctor or pharmacist about which vaccines you need.

Screening programmes

Regular check-ups with your doctor can catch early signs of heart problems, especially if you have risk factors like high blood pressure or diabetes. If you have a family history of heart failure, tell your doctor.

Complications

If left untreated

• Worsening shortness of breath and fatigue that limit daily activities
• Fluid buildup in the lungs (pulmonary edema) that can be life-threatening
• Kidney damage or failure
• Irregular heart rhythms that increase the risk of stroke
• Hospital stays for heart failure exacerbations

Long-term outlook

Heart failure with preserved ejection fraction is a long-term (chronic) condition, but with the right treatment and lifestyle changes, many people live well for years. The outlook has improved with newer treatments. Staying on top of your health and working closely with your doctors can help you manage symptoms and keep doing the things you love.

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