Heart Failure with Preserved EF

Heart failure is a clinical syndrome characterised by symptoms of shortness of breath, effort intolerance and fluid retention. These symptoms are caused by abnormalities in heart function. It is also commonly called 'congestive cardiac failure' or 'congestive heart failure'.

Heart failure with preserved ejection fraction (HFpEF) refers to a subset of heart failure, where the 'ejection fraction', or contraction strength of the heart muscles is 'preserved', or >50% (normal ejection fraction is around 55 – 65%). Despite the preservation of the ejection fraction, patients suffer from poor relaxation ('stiffening') of the heart muscle walls, resulting in congestion.

The exact cause of HFpEF is unknown. However, it is associated with many conditions, including:

• Advanced age
• Female sex
• Elevated body weight/ obesity
• Poorly controlled high blood pressure
• Diabetes mellitus
• Atrial fibrillation

• Shortness of breath (on exertion or during rest)
• Decreasing effort tolerance
• Difficulty in breathing when lying flat
• Waking up breathless at night
• Chronic fatigue
• Swelling of ankles/ legs/ abdomen

HFpEF is a clinical syndrome diagnosed through integrating various medical data and information, including:

• Patient symptoms
  • Typical symptoms of shortness of breath on exertion, inability to sleep lying flat, worsening fatigue etc
• Clinical examination
  • Signs of fluid retention (leg swelling, abdominal swelling, fluid sound in lungs)
• Blood tests
  • Red blood cell counts, kidney/ liver function, thyroid hormone level
  • NT-proBNP: hormone produced by the heart, which is elevated in heart failure
• Electrocardiogram ('ECG')
  • Electrical tracing of the heart, looking for heart rhythm abnormalities, as well as signs of underlying structural heart abnormalities
• Chest radiograph
  • X-ray examination, looking for abnormal heart enlargement/ abnormal fluid collection in the lungs
• Specialised cardiac imaging
  • Echocardiogram: Ultrasound examination which allows doctors to evaluate important morphological features of the heart, including the ejection fraction
  • Cardiovascular magnetic resonance imaging ('Cardiac MRI'): Specialised scan looking specifically at the heart muscles, to look for underlying heart muscle abnormalities that can mimic HFpEF (such as hypertrophic cardiomyopathy/ amyloid cardiomyopathy)
  • Stress echocardiogram: to look for evidence of poor heart muscle relaxation during exercise/ exertion
• Invasive investigations
  • Coronary angiogram: look for blockages in the heart blood vessels from atherosclerotic plaques
  • Right heart study: assess pressures in the heart chambers, as well as the blood delivery effectiveness of the heart
  • Exercise stress right heart study: to look for elevation of pressures in the heart chambers with exercise

Acute decompensation

When a patient is admitted to the hospital for severe shortness of breath and fluid retention, the treatment will be targeted at reversing the episode of decompensation and getting the patient back to his/ her baseline functioning.

Treatment of acute decompensated HFpEF may include:

• Oxygen supplementation if necessary
• Medications to remove excess fluid ('diuretics')
• Improve control of co-morbid conditions (high blood pressure/ diabetes mellitus/ obstructive sleep apnoea etc)
• Education/ counseling to prevent repeat episodes of decompensation

Chronic management

HFpEF is a chronic condition that requires long term treatment and follow up. The Heart Failure Programme at NUHCS provides a multi-disciplinary approach to the chronic management of HFpEF, which will include:

Lifestyle modifications

• Smoking/ alcohol cessation
• Fluid and salt restriction
• Regular monitoring of body weight/ blood pressure
• Exercise as recommended by the heart failure team
• Cardiac rehabilitation programme enrollment

Medical therapy

• Use of medication to improve long term outcome of patients diagnosed with HFpEF
  1. Sodium-glucose co-transporter 2 (SGLT-2) inhibitor
• Medications to improve patients' symptoms and reduce the risk of hospitalisation
  1. Diuretics ('water retention tablets')
  2. Medications to manage co-morbid conditions (high blood pressure/ diabetes mellitus)

Suitable patients will be followed up in the specialised Heart Failure Clinic, a multi-disciplinary clinic aimed at providing holistic management of heart failure, to improve the long-term outcome for our patients.