Heart Failure with Preserved Ejection Fraction Clinic

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

HFpEF is the type of heart failure where the heart pumps well but doesn't relax properly between beats. This causes the heart to become stiff, leading to blood backing up into the lungs, especially when you're walking or exercising. This can cause shortness of breath and swelling in the legs or abdomen.

If HFpEF is not treated, it can lead to worsening symptoms, frequent hospital visits and could eventually negatively impact other organs like the kidneys or liver.

What Causes HFpEF?

Heart failure with preserved ejection fraction is usually caused by the complex interplay of long-term stressors on the heart. Most often this is related to the following chronic conditions:

• High blood pressure (hypertension)
• Obesity
• Diabetes
• Sleep apnea
• High cholesterol (hyperlipidemia)
• Coronary artery disease
• Kidney issues

However, there are also specific conditions that can directly cause similar symptoms (such as cardiac amyloidosis, hypertrophic cardiomyopathy, cardiac sarcoidosis, etc). It is important to get an accurate diagnosis to guide treatment.

If you have one or more of the risk factors above, along with shortness of breath, you may benefit from referral to a dedicated HFpEF clinic.

Common Symptoms of HFpEF

We find that many patients who have heart failure with preserved ejection fraction are more likely to experience:

• Shortness of breath when walking or exercising
• Difficulty breathing when lying flat
• Swelling in the legs or abdomen
• Hospital visits needing IV "water pills"

Our heart failure team will work with you to develop a symptom management plan designed to relieve discomfort or pain and restore heart function so you can return to normal daily life.

Diagnosing HFpEF

Because the symptoms associated with heart failure with preserved ejection fraction can have many causes, it can be tricky to diagnose HFpEF. Doctors may use heart ultrasounds, blood tests and the most accurate test, right heart catheterization with exercise.

Right heart catheterization with exercise is a special diagnostic procedure used to assess how the heart and lungs respond to exercise. It provides important information about the pressure in the right side of the heart and pulmonary arteries during both rest and exercise.

What happens during the procedure?

1. Preparation: This procedure is done in a cardiac catheterization laboratory. A catheter (a thin, flexible tube) is inserted through a large vein, typically in the neck or groin and threaded into the right side of the heart.
2. Measurements at Rest: Once the catheter is in place, doctors measure pressures in the right atrium, right ventricle, pulmonary arteries, and pulmonary capillaries at rest. Oxygen levels are also measured.
3. Exercise Phase: In some cases, the results at rest are inconclusive, and exercise is used for an accurate diagnosis. Patients will be asked to pedal in the recumbent position using pedals on the cardiac catheterization laboratory table.
4. Measurements During Exercise: The heart and lung pressures are measured again while the patient exercises. This provides data on how well the heart and lungs handle increased demand.

How is HFpEF Treated?

The current, approved treatments for HFpEF include use of sodium-glucose co-transporter 2 inhibitors (i.e. dapagliflozin or empagliflozin), as well as use of mineralocorticoid antagonists (i.e. spironolactone, eplerenone or finerenone) and diuretics (i.e. “water pills).

In patients with difficult-to-control swelling and/or frequent heart failure hospitalizations, we can also implant a remote monitoring sensor that sends the patient’s fluid levels to our nursing team every morning and their “water pills” are adjusted in a personalized fashion.

Additionally, it is important to evaluate and treat patients for related co-morbidities, such as obesity, hypertension, coronary artery disease, atrial fibrillation, obstructive sleep apnea, chronic kidney disease, metabolic dysfunction-associated liver disease (MASLD), and anemia. Specifically, managing obesity with glucagon-like peptide 1 (GLP1) receptor agonists (i.e. semaglutide) have shown promising results for improving HFpEF symptoms and outcomes in recent clinical trials.

Clinical Trials for Heart Failure Advancements

There are limited, approved treatments for HFpEF, but there are many medications and devices undergoing multi-center clinical trials. With clinical trials, we give our patients access to leading-edge medical and technological advances in the treatment of HFpEF before they are available universally.

Our HFpEF clinic is currently enrolling patients in both device-based and medicine-based trials, delivering new therapies to a complex heart condition. While not all patients may qualify for a clinical trial, it is important everyone have access to this information to make an informed decision on the best options to improve their health.

We are currently enrolling in the following trials:

• RESPONDER-HF Trial: Re-Evaluation of the Corvia Atrial Shunt Device in a Precision Medicine Trial to Determine Efficacy in Mildly Reduced or Preserved Ejection Fraction (EF) Heart Failure: https://clinicaltrials.gov/study/NCT05425459 
• LEVEL Trial: A Phase 3, Double-Blind, Randomized, Placebo-Controlled Study of Levosimendan in Pulmonary Hypertension Patients With Heart Failure With Preserved Left Ventricular Ejection Fraction (PH-HFpEF): https://clinicaltrials.gov/study/NCT05983250