HFpEF: A Complication of Hypertension Worth Noting

Hypertension is recognized as the most important risk factor for heart failure with preserved ejection fraction. Please, treat to target!

First, the definition of diastolic dysfunction, or heart failure with preserved jection fraction (HFpEF). Under normal circumstances, after systole, low ventricular pressures and vigorous myocardial elastic recoil allow ventricular filling without a significant rise in pressure. With HFpEF, a “stiff” ventricle can increase filling pressure, transmitting that additional pressure to the left atrium and pulmonary circulation, eventually leading to heart failure.1 What is the most important risk factor for HFpEF? It has become clear; it’s hypertension.2

The National Health and Nutrition Examination Survey estimates that 5.7 million Americans >20 years of age have heart failure and HFpEF comprises 50% of heart failure admissions to the hospital; a 46% increase in these numbers is predicted by 2030.3 Intense research has implicated multiple factors in the etiology of HFpEF syndrome including systemic inflammation, LV hypertrophy, slowed LV relaxation, increased LV stiffness and remodeling, increased peripheral vascular resistance, impaired endothelial dysfunction, increased pulmonary vascular resistance, and neurohormonal activation.3 Ventricular-arterial coupling has been suggested as a more unifying theory.3 When arterial circulation becomes “stiffer,” the afterload increase is responsible for elevated blood pressure and progressive loss of LV elasticity with higher filling pressures.3 Groups more prone to develop HFpEF include those with obesity, diabetes, hypertension, and chronic kidney disease. Is there a specific agreed-upon treatment for HFpEF? The short answer is, "No," but some maneuvers have been proven to help.

In a 2013 trial, 527 persons with early-stage hypertension were given antihypertensive therapy.3,4 After 24 and 48 weeks of treatment, echocardiographic markers documented an improvement in diastolic function. Myriad antihypertensive classes have been tried in HFpEF. Irbesartan did not improve outcomes in HFpEf (irbesartan and agents in the renin-angiotensin group are effectivein in HF with reduced EF).3 The same can be said for beta blockers.3 Spironolactone did not demonstrate an effect on mortality, but did decrease hospitalizations in persons with HFpEF.3 Right now, a treat-to-target strategy should be used when treating hypertension in HFpEF, but favored drug classes have not become apparent. Diuretics may be required for patients with heart failure as a result of HFpEF.

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1. Jake Samuel T, Beaudry R, Sarma S, et al. Diastolic stress testing along the heart failure continuum. Curr Heart Fail Rep (2018)  https://doi.org/10.1007/s11897-018-0409-5.
2. Nadruz W, Shah AM, Solomon SD. Diastolic dysfunction and hypertension.  Med Clin N Am. 2017; 101:7-17.
3. Lekavich CL., Barksdale DJ, Neelon V, and Wu JR. Heart failure preserved ejection fraction (HFpEF): an integrated and strategic review. Heart Fail Rev. 2015 20: 643-653.
4. Lam CS, Shah AM, Borlaug BA, et al. Effect of antihypertensive therapy on ventricular-arterial mechanics, coupling, and efficiency. Eur. Heart J. 2013; 34:676-683.