Heart failure with preserved ejection fraction (HFpEF) is a type of heart failure that affects the left side of the heart. It occurs when the lower left chamber of the heart, called the left ventricle, is unable to relax and fill with blood in the normal way.

People may also refer to HFpEF as diastolic failure or diastolic dysfunction.

This article looks at HFpEF in more detail, including its symptoms, causes, and treatment.

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HFpEF is a type of left-sided heart failure. Left-sided heart failure occurs when the left ventricle does not function as it should. Another type is heart failure with reduced ejection fraction (HFrEF), in which the heart is unable to pump blood effectively.

The function of the left ventricle is to pump oxygenated blood to the rest of the body. It is larger than the other chambers of the heart, as it is responsible for most of the pumping action of the heart.

The American Heart Association (AHA) states that in people with HFpEF, the left ventricle loses its ability to relax as normal between heartbeats. This is because the muscle has become stiff.

As a result, the heart is unable to fill with blood properly during the resting periods between heartbeats. As the blood continues to enter the left ventricle after each heartbeat, this can lead to higher blood pressure in this chamber.

Ejection fraction is a measure of how well the heart is pumping blood. Doctors give the score as a percentage.

Doctors use ejection fraction percentages to categorize left-sided heart failure. According to a 2022 article, people with HFpEF have an ejection fraction of more than 50%.

HFpEF affects about 50% of all people with heart failure. In the United States, there are 6.6 million cases of heart failure each year, almost half of which are HFpEF.

Research suggests that HFpEF is more likely to affect older adults and that it is more prevalent among females. Among those with HFpEF, 79% are female, whereas females represent 49% of those with HFrEF.

The symptoms of HFpEF may include:

Other possible symptoms of left-sided heart failure include:

  • breathing that feels uncomfortable or more difficult when lying down
  • shortness of breath at night that wakes people from sleeping
  • weight gain
  • liver congestion, which can cause pain in the upper right abdomen

Left-sided heart failure may occur due to:

Risk factors specifically for HFpEF include:

To treat HFpEF, doctors will focus on treating the underlying cause or any factors that may be contributing to HFpEF. This may involve:

  • controlling blood pressure levels
  • managing arrhythmias
  • restoring blood flow into any blocked blood vessels
  • taking antimineralocorticoid drugs, which help the kidneys move excess fluid and salt out of the body

Doctors may use the following criteria to diagnose heart failure:

Major criteriaMinor criteria
excess fluid in the lungs
• an enlarged heart
• pressure on the liver causes swelling of the neck veins
• shortness of breath when lying down
• swelling in the ankles
• shortness of breath during activity
• an enlarged liver
• a cough at nighttime
• fluid buildup around the lungs
• heart rate above 120 beats per minute

A person will only receive a diagnosis of heart failure if they meet at least two major criteria or one major and two minor criteria.

To diagnose HFpEF in people with heart failure, doctors will also measure ejection fraction. An ejection fraction measurement above 50% indicates HFpEF.

Doctors also look for the following indicators of HFpEF:

  • a specific sound of the heart, called the S3 heart sound
  • an abnormal pulse in the chest, called the apical pulse
  • the bulging of veins in the neck

As part of the diagnostic process for HFpEF, doctors may carry out the following tests:

  • a physical assessment
  • a natriuretic peptide test, which is a blood test to measure substances that the heart makes, with high levels indicating that the heart is not pumping as effectively as normal
  • a metabolic panel, which is a blood test to check sodium levels, as low levels may indicate heart problems
  • liver function tests
  • EKG, which measures the electrical activity of the heart
  • an echocardiogram, which uses ultrasound to create an image of the heart and helps measure ejection fraction to differentiate between HFpEF and HFrEF
  • a coronary angiogram, which uses an X-ray and special dye to create an image of the heart’s blood vessels

Outcomes can vary for each individual and may depend on which other health conditions are present.

Almost 50% of hospitalizations for heart failure in the U.S. are due to HFpEF.

HFpEF has a mortality rate of more than 50% at 5 years following hospitalization. However, HFpEF may have a lower mortality rate than HFrEF.

Factors that may worsen the outlook for people with heart failure include:

  • older age
  • being male
  • very low blood pressure
  • kidney failure
  • elevated heart rate
  • low ejection fraction

Managing blood pressure, staying physically active, eating a nutritious diet, and controlling risk factors such as diabetes and diseases of the arteries may all help reduce the risk of heart failure.

The AHA states that by treating and managing the symptoms, it can be possible for people to have a full and enjoyable life with heart failure.

People will need to contact a doctor if they experience any of the following symptoms:

  • shortness of breath
  • swelling in the lower legs or abdomen
  • fatigue
  • intolerance to exercise

The AHA lists the following symptoms as emergency warning signs:

  • a frequent, dry, hacking cough
  • feeling short of breath when resting
  • swelling or discomfort in the lower body
  • sudden weight gain of more than 2–3 pounds in a 24-hour period or of 5 pounds in a week
  • new or worsening state of confusion, dizziness, depression, or sadness
  • loss of appetite
  • difficulty breathing when lying flat

Anyone who experiences any of the above will need to seek medical attention straight away.

HFpEF is a type of heart failure in which the left ventricle is unable to relax and fill with blood as normal. It is a common type of heart failure, accounting for about half of all heart failure cases.

The treatment for HFpEF may vary for each individual, but it can include managing blood pressure, taking medications, and making lifestyle adjustments.