Treatment of heart failure with preserved ejection fraction

Approximately half of all patients with chronic heart failure (HF) have a preserved ejection fraction (HFpEF) (1). Morbidity and mortality are high, and similar to patients with systolic heart failure (SHF) (2). In contrast to the wealth of data available from large-scale clinical trials in SHF, there is little evidence to guide treatment decisions in HFpEF (3). This relates to an incomplete pathophysiologic understanding, the lack of randomized trial data currently available, and the relatively equivocal findings noted in the studies published to date. Treatments with dramatic benefits in SHF have had less impressive effects in HFpEF (4,5). Fundamental disparities in ventriculoarterial mechanical properties in HFpEF produce different clinical responses to common drugs such as vasodilators and diuretics, and novel agents more specifically targeting these abnormalities may ultimately prove more effective (6). In this chapter, we shall first examine the pathophysiology of HFpEF to better predict and understand responses to various treatments. Data regarding specific medications, most of them commonly used in SHF, will be reviewed. Finally, future therapies that are or will soon be tested in clinical trials will be explored.