By Shamard Charles, MD, MPH 

 Medically reviewed by Richard N. Fogoros, MD

About half of all people with heart failure have a heart that pumps normally—or at near-normal levels. Heart failure with preserved ejection fraction (HFpEF), also known as diastolic heart failure, causes about half of the five million cases of heart failure in the United States.1

Heart failure type is based on ejection fraction—or the amount of blood pumped out of the left ventricle with each contraction. The two most common types of heart failure are with or without preserved ejection fraction, or more simply, diastolic and systolic heart failure. 

In a normal heart, the left ventricle squeezes out most, but not all, of the blood in its chamber. An ejection fraction of 55% or more is considered normal.

Abnormalities in the ventricles’ ability to relax and passively fill up with blood can lead to a decline in the volume of blood pumped out of the heart to the body.2 HFpEF is most common among older adults and women. 

This article discusses the symptoms, causes, diagnosis, and treatment of heart failure with preserved ejection fraction.

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Heart Failure With Preserved Ejection Fraction Symptoms

Most of the symptoms of HFpEF result from an accumulation of blood and fluid in the lungs, veins, and tissues of the body. Symptoms of HFpEF include:1

  • Chest pain

  • Fatigue

  • Weakness

  • Shortness of breath, especially on exertion

  • Orthopnea, or shortness of breath when lying down

  • Paroxysmal nocturnal dyspnea

  • Exercise intolerance

  • Fast or irregular heartbeat

  • Peripheral edema, or swelling of the feet, ankle, or legs

  • Weight gain

  • Nausea

  • Persistent coughing or wheezing

  • Having to urinate more than usual (polyuria) or at night (nocturia)

Causes

If you have HFpEF, your heart muscle can pump normally, but it is stiff and therefore unable to relax and fill properly with blood. As you get older, the heart and blood vessels become less elastic, increasing your risk of developing HFpEF.

Chronic medical conditions can damage the heart and other organ systems of the body. Often, but not always, people have more than one health problem that can impair their left ventricle’s ability to fill properly with blood during diastole.

Other causes of HFpEF besides aging include:2

  • High blood pressure: Chronic hypertension is one of the most common causes of diastolic heart failure. High blood pressure over a long period of time means the heart has to work harder to pump blood through the body. As a result, the heart gets more muscular and stiffer, which impacts its ability to relax during the resting stages of the cardiac cycle when the heart fills up with blood. 

  • Diabetes: High blood sugar levels are toxic to blood vessels and may cause them to stiffen. Like high blood pressure, the heart muscle can thicken when it has to work harder against increased pressure.

  • Coronary artery disease: Blockages in the heart’s blood vessels allow less blood to flow through your heart than usual. Very low blood flow to the heart can lead to ischemia, or death of heart muscle cells, preventing the heart from relaxing and filling as it normally would. 

  • Pericardial disease: Fluid around the heart, called pericardial tamponade, or a thickened outer covering on the heart, called pericardial constriction, can limit the heart’s ability to fill with blood.

  • Other heart conditions: There are several heart conditions that cause the left ventricle to thicken, compromising its ability to relax and fill with blood. Aortic stenosis, which is a narrowing of the aortic valve, and hypertrophic cardiomyopathy, an inherited heart muscle disorder that leads to a very thickened left ventricular wall, are two examples. 

  • Obesity: Increased fat padding around the heart results in the heart having to work harder to pump.

  • Sedentary lifestyle: A lack of physical activity can put you at higher risk of high blood pressure, diabetes, coronary artery disease, and obesity, all of which contribute to diastolic heart failure.

  • Obstructive sleep apnea (OSA): OSA is characterized by partial or complete cessation of breathing during sleep. This leads to a complex set of changes in the body, including increases in blood pressure, diminished oxygen delivery to the heart, and increased sympathetic nervous system activity (SNA). As a result of these changes, there is a mismatch between oxygen supply and demand, which may predispose you to cardiac ischemia and arrhythmia, left ventricular hypertrophy, left ventricular enlargement, and both systolic and diastolic heart failure.3

Diagnosis

A diagnosis of HFpEF is made based on your:

  • Clinical history

  • Physical examination

  • Laboratory data

  • Echocardiography

When necessary, cardiac catheterization may also be used.

Clinical signs and symptoms of heart failure, plus evidence of normal or near-normal left ventricular (LV) systolic heart function with an LV ejection fraction over 50% and an assessment of the heart’s diastolic characteristics with an echocardiogram, are essential to making a diagnosis.2

The New York Heart Association’s classification system is the simplest and most widely used method to gauge symptom severity.

Class I

  • No limitations of physical activity

  • No heart failure symptoms

Class II

  • Mild limitation of physical activity

  • Heart failure symptoms with significant exertion; comfortable at rest or with mild activity

Class III

  • Marked limitation of physical activity

  • Heart failure symptoms with mild exertion; only comfortable at rest

Class IV

  • Discomfort with any activity

  • Heart failure symptoms occur at rest

Treatment

There is no one-size-fits-all approach to managing heart failure. Treatment of HFpEF should take the whole person into account, not just your heart.

A sound treatment plan usually starts with controlling blood pressure and relieving fluid overload that can cause swelling or shortness of breath, and addressing anticipated mental, emotional, and physical changes that you may incur.

Is There a Cure for HFpEF?

HFpEF is a progressive condition with no cure, but its progression can be slowed or halted in many people through aggressive treatment and lifestyle changes. In most people, heart failure is a chronic condition that requires lifelong treatment.

Most treatments are geared toward slowing down the progression of your heart failure and managing your symptoms.

Your doctor will likely suggest that you follow a treatment regimen that includes a combination of:4

  • Diet and lifestyle changes

  • Medicines

  • Sometimes a device to protect your heart from abnormal rhythms

If you have heart failure, the following lifestyle changes will help manage your symptoms:

  • Regular low-intensity aerobic exercise to strengthen the heart

  • Eating a heart-healthy diet

  • Cutting back on salt (sodium)

  • Limiting your alcohol consumption

  • Quitting smoking

The best way to manage diastolic heart failure is to treat its underlying cause, such as hypertension, diabetes, or coronary artery disease.

The efficacy of medication in the treatment of diastolic heart failure is inconclusive, but diuretics are commonly used to manage HFpEF symptoms by removing excess fluid from the body. SGLT2 inhibitors may also be recommended, as they've been shown to reduce the risk of cardiovascular death and hospitalization for heart failure. Other medications such as the use of angiotensin receptor blockers, ARN inhibitors, and mineralocorticoid receptor antagonists (such as spironolactone) may be considered for certain people to help decrease hospitalizations.4

The American College of Cardiology (ACC) and the American Heart Association (AHA) recommend that cardiologists manage heart failure by its stage:4

  • Stage A includes managing heart failure risk factors like high blood pressure and high cholesterol. This may include putting you on a ACE inhibitor and a statin.

  • Stage B is diastolic dysfunction without symptoms. In this case your cardiologist may prescribe medications to help ease the load on your heart.

  • Stage C is structural heart disease with prior or current symptoms of heart failure. Those with a reduced ejection fraction will likely be prescribed a combination of medications, including diuretics, to help relieve symptoms and prevent further damage.

  • Stage D is advanced heart failure. Treatment for this stage may require a heart transplant or palliative care.

The ACC and AHA also recommend starting or continuing a combined endurance and resistance training program for patients with HFpEF to improve:4

  • Exercise capacity

  • Physical functioning

  • Diastolic function

Prognosis

There is no cure for HFpEF, but timely management greatly increases your chances of living a happy and healthy life. 

HFpEF is a progressive condition, so no matter the severity, diastolic dysfunction is associated with increased mortality, even if you are asymptomatic. Older age, hypertension, diabetes, and coronary artery disease increase your risk of heart failure.

Hypertension and type 2 diabetes are preventable risk factors that should be closely monitored in people with HFpEF.

The outlook for HFpEF is especially poor if you have been hospitalized, with one-year mortality rates as high as 25% among older patients and five-year mortality rates of 24% for those over the age of 60 and 54% among those older than 80 years.5

Factors associated with a worse prognosis include:

  • Higher levels of NT-proBNP

  • Older age

  • Diabetes

  • Past history of heart attack

  • Chronic obstructive pulmonary disease (COPD)

  • Reduced kidney function

  • Right ventricular remodeling on echocardiogram

Of note, people with HFpEF tend to have a better short-term prognosis compared to those with systolic heart failure.

Coping

If you have heart failure, you know that coping is an ongoing challenge. Feelings of fear, anger, emotional distress, and depression may arise after the initial diagnosis.

Physical limitations can be tough to accept, and you may not be ready to make all the changes that are asked of you. All these emotions are natural, and talking to friends and family can help you navigate some seemingly bleak moments. 

From adapting to taking daily medication to making adjustments to your social life, living with heart failure is not easy. The key to living a healthy life is to make lifestyle changes that lessen the chances of having heart failure exacerbations.

Also, be in tune with your symptoms and contact a healthcare professional immediately if you sense that your condition is worsening. The sooner you get help, the better you will feel. 

Limiting stress, quitting smoking, and exercising may also help your mental health. If you have HFpEF, addressing your mental and emotional health will be more important than ever, as depression and anxiety can lead to unhealthy ways of coping, such as smoking, drinking, drug use, or turning to “comfort” foods that are usually not heart healthy. 

If you are feeling the following symptoms for two or more weeks, you may be experiencing depression:

  • Feeling sad

  • Not enjoying normal activities

  • Trouble concentrating

  • Fatigue

  • Withdrawal from friends and family

  • Feeling hopeless and worthless

  • Excessive sleepiness

  • Loss of appetite

  • Suicidal thoughts

Recognizing these symptoms is the first step to taking action, which may include seeing a mental health provider who may suggest cognitive behavioral therapy, medication, or simply staying active and communicating how you feel with family and friends.