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What is heart failure with preserved ejection fraction (HFpEF)?



Paul Leeson 
Founder and Chief Medical Officer of Ultromics

An estimated 6.4 million people in the United States have heart failure, according to the Centers for Disease Control and Prevention (CDC). [1] More than half of those individuals have heart failure with preserved ejection fraction (HFpEF), where the heart doesn’t relax properly between heartbeats.

This is also known as diastolic heart failure, and it can lead to decreased blood flow and other complications. However, with the right treatment, individuals can effectively manage these symptoms.


OverviewSymptoms and CausesDiagnosisManagement and TreatmentOutlook




What is HFpEF?


Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome in which patients have signs and symptoms of HF as the result of high left ventricular (LV) filling pressure, despite normal or near-normal LV ejection fraction (EF).

Most patients with HFpEF also display normal LV volumes and an abnormal diastolic filling pattern (i.e, diastolic dysfunction). HFpEF occurs when the muscle in the left ventricle stiffens and is less able to relax, leading the pressure inside the heart to rise. 

This prevents it from filling with enough blood during the cardiac cycle’s diastole phase. The filling occurs with higher pressure, which reduces the amount of blood available to pump throughout the body during the systole phase. As a result, less oxygen-rich blood is delivered to organs and other tissues.


What is the difference between HFpEF and HFrEF?


We classify heart failure based on which of these two functions is abnormal. In HFrEF, the left ventricle is too weak, rather than too stiff. It can’t contract properly.

It may fill with enough blood during the cardiac cycle’s diastole phase, but it can’t pump that blood with enough force during the systole phase. This leads to a reduced amount of blood ejected (ejection fraction).

If the heart pumps normally but is too stiff to fill properly, the condition is known as heart failure with preserved ejection fraction (HFpEF).


A normal EF is 55 to 70%. An ejection fraction below 50% is indicative of HFrEF. 

However, HFpEF may occur with an EF greater than or equal to 50%, which suggests a normal ejection fraction. 


With HFpEF, there’s less blood coming into the stiffened left ventricle, but the heart is still able to pump that blood back out of the ventricle.


Symptoms and causes


What causes HFpEF?


Cellular and Molecular Differences between HFpEF and HFrEF [2] 

Cellular and Molecular Differences between HFpEF and HFrEF: A Step Ahead in an Improved Pathological Understanding


Many conditions are associated with HFpEF. These include:

  • Atrial fibrillation (Afib)

  • Coronary artery disease

  • Diabetes

  • High blood pressure (hypertension)

  • Obstructive sleep apnea (OSA)

  • Obesity

  • Chronic kidney disease

  • Amyloidosis or other infiltrative heart diseases


What are the symptoms of diastolic heart failure?


Diastolic heart failure has many of the same symptoms as other types of heart failure.

Individuals with diastolic heart failure may experience:

  • Coughing or wheezing

  • Dizziness

  • Edema (swelling), especially in the legs, ankles, feet, or abdomen

  • Fatigue

  • Shortness of breath, especially when lying flat or with exertion

  • Decreased exercise tolerance




How is HFpEF diagnosed?


Diagnosing HFpEF is challenging and relies upon the presence of symptoms and signs of heart failure, preserved left ventricular systolic function, and evidence of diastolic dysfunction.


 Currently, three criteria must be met to establish the diagnosis: 



- Clinical symptoms consistent with heart failure


- Preserved EF (at least 50%)


- Evidence of cardiac dysfunction



The 2022 American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) and the 2021 European Society of Cardiology (ESC) both provide evidence-based guides for the diagnosis and treatment of heart failure (HF). The diagnostic approach is the same between both guidelines.

The combination of clinical assessment, followed by natriuretic peptide measurement, echocardiographic indices of diastolic function, staging, and treatment initiation are all proposed in the diagnostic evaluation of patients with suspected HFpEF. 

The clinical composite score H2FPEF may also be used to aid risk stratification and to guide diagnostic workup. 

This score combines patient risk factors – such as obesity, AF, and age greater than 60 – into a weighted score. Patients with a score of less than 2 have a low likelihood of having HFpEF, whereas patients with a score greater than 6 have a high likelihood of this disorder. A further workup is indicated for patients in the midrange of the score.

If the diagnosis remains uncertain after testing,  an exercise stress test may be useful for unmasking heart failure symptoms in patients with HFpEF and help with classification. 

Cardiac catheterization or coronary angiography may also be performed if more information is needed after non-invasive testing.

[5] Diagnostic algorithm for patients with suspected HF.


Management and Treatment


How is HFpEF treated?


Proper treatment can help patients manage symptoms and improve heart function. However, there are few effective treatment options for HFpEF.

Patients may benefit from lifestyle changes. Additionally, diuretics may be prescribed to limit fluid build-up in the tissues. 

Medications might also be prescribed to manage other chronic health conditions or cardiovascular risk factors.

This might include options that: 

  • Reduce the heart rate so that the heart spends more time in diastole (allowing more time for the heart to fill)

  • Lower blood pressure

  • Reduce cholesterol levels

  • Decrease risk of blood clots for patients with atrial fibrillation

  • Control blood sugar levels for patients with diabetes

While there are a number of options for treating heart failure, there have been barriers to the development of effective treatment targeting HFpEF. This is due to factors such as the incomplete understanding of the pathophysiology of HFpEF, the likelihood that there is substantial pathophysiologic heterogeneity among affected patients, and the interplay of various risk factors. 

This underscores the need for expanded research initiatives, given the rapidly increasing number of patients with this form of cardiac failure.

What is HFpEF graph

[5] The 2022 2022 AHA/ACC/HFSA heart failure guideline provides recommendations based on contemporary evidence for treating HFpEF. 


HFpEF Outlook


HFpEF is the greatest unmet need in cardiovascular medicine. A study in the New England Journal of Medicine found HFpEF has a five-year survival rate of just 35-40%. [3]

There is no effective treatment for HFpEF, but patients can manage symptoms by changing their lifestyles or taking heart medications.


Patient outlook depends on:



- How severely heart function is affected


- The amount of fluid retention


- Age and overall health


- The treatment a patient might receive


Getting treatment for HFpEF and other chronic conditions, alongside practicing healthy habits, may help improve a patient’s quality of life and outlook. 


The key takeaways:


  • More than half of people with heart failure have HFpEF.

  • This condition reduces the amount of oxygen-rich blood that the heart delivers to other tissues and organs and increases pressure in the heart. 

  • It can cause uncomfortable symptoms and put individuals at risk of potentially life-threatening complications.

  • It’s important to get treatment for HFpEF and other chronic health conditions. However, treatment for HFpEF is limited. 

  • Medications and other treatments may be prescribed, alongside suggestions to make lifestyle changes.

Learn more about HFpEF and how precision detection can help improve outcomes.


  1. Centers for Disease Control and Prevention. Heart failure [Internet]. Centers for Disease Control and Prevention. 2023.
  2. Simmonds SJ, Cuijpers I, Heymans S, Jones EAV. Cellular and Molecular Differences between HFpEF and HFrEF: A Step Ahead in an Improved Pathological Understanding. Cells. 2020;9(1):242.
  3. Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM. Trends in prevalence and outcome of heart failure with preserved ejection fraction. The New England journal of medicine [Internet]. 2006;355(3):251–9.
  4. Upadhya B, Kitzman DW. Heart Failure with Preserved Ejection Fraction in Older Adults. Heart Failure Clinics. 2017 Jul;13(3):485–502.
  5. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2022;79:263-421

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