Heart failure with normal ejection fraction (HNEF) – HFpEF

Heart failure with normal ejection fraction (HNEF) – HFpEF

Heart failure with normal ejection fraction (HNEF) – HFpEF: Signs and symptoms of heart failure with ejection fraction > 50%, and diastolic dysfunction constitutes the group of heart failure with normal ejection fraction (HNEF). HNEF contributes to about 50% of heart failure. Diastolic dysfunction is common in elderly, but all do not develop HF. Elderly women, hypertensive, those with left ventricular hypertrophy (LVH), obesity, diabetes, renal insufficiency, anemia and atrial fibrillation (AF) are predisposed to HNEF. 15% of those treated for HNEF and discharged, do develop acute coronary syndrome (ACS) later. This indicates the association of HNEF with coronary artery disease (CAD).

Tissue Doppler imaging (TDI) is useful in delineating abnormalities in longitudinal systolic function often associated with HNEF. Usual indices of systolic function are normal in HNEF. Left atrial (LA) pressure is elevated and LA is dilated, often leading to AF. BNP is elevated in HNEF as in systolic dysfunction.

Chest X-ray (CXR) shows pulmonary venous congestion and pulmonary edema. ECG may show left atrial overload (LAO), LVH, ischemia or AF. Echo shows normal left ventricular ejection fraction (LVEF) and features of diastolic dysfunction. E/A reversal of mitral inflow velocity is the usual finding. E/E’ using TDI correlates well with LA pressure. If above 15, it is indicative of HNEF.

Management is by volume management with drugs like frusemide. But excessive diuresis can lead to hypotension. If there is renal failure, dialysis has to be considered. If atrial fibrillation is present, it has to be managed. Beta blockers may be useful by reducing the heart rate and increasing the diastolic filling period. ACE / ARBs have a limited role in HNEF. Coronary revascularisation in indicated cases will be useful. Digitalis has very little role in HNEF. NT-Pro BNP is the strongest predictor of poor prognosis in HNEF.

The revised terminology for HNEF is HFrEF – heart failure with preserved ejection fraction.