Current Approach to Heart Failure with Preserved Ejection Fraction: An Updated Review

Résumé fourni par la source

Heart failure with preserved ejection fraction (HFpEF) accounts for approximately half of all heart failure cases and presents a high morbidity and mortality rate, similar to the reduced ejection fraction phenotype.It is characterized by signs and symptoms of heart failure, a left ventricular ejection fraction (LVEF) ≥ 50% and evidence of diastolic dysfunction, ventricular hypertrophy or elevated natriuretic biomarkers.Its prevalence increases with age, is more common in women and is associated with hypertension, obesity, diabetes and atrial fibrillation.Diagnosing HFpEF is challenging, as symptoms such as dyspnea and fatigue are nonspecific.Clinical-echo scoring systems, such as the H 2 FPEF score, combine risk factors and imaging parameters, showing a sensitivity of 83% and specificity of 92% for HFpEF identification.Biomarkers like B-type natriuretic peptide (BNP) assist in risk stratification and prognosis.Advanced imaging techniques, including cardiac magnetic resonance imaging for quantifying fibrosis and assessing myocardial relaxation, offer greater diagnostic accuracy.Historically, treatment focused on symptom control and comorbidity management diuretics, blood pressure control, atrial fibrillation management and cardiac rehabilitation-without demonstrating clear mortality benefit.In 2019, the PARAGON-HF trial evaluated sacubitril-valsartan versus valsartan in patients with LVEF ≥ 45%, failing to reach statistical significance for the primary endpoint but suggesting benefit in subgroups with borderline EF and in women.A true therapeutic breakthrough came with sodium-glucose co-transporter 2 inhibitors (SGLT2i).In the EMPEROR-Preserved trial, empagliflozin reduced the risk of cardiovascular death or heart failure hospitalization by 21% and in the DELIVER trial, dapagliflozin reduced these events by 18%, regardless of diabetes status.These results led to SGLT2i being recommended as the first pharmacological class to modify outcomes in HFpEF.Future perspectives include therapies targeting fibrosis and myocardial remodeling, myofibril modulators and antifibrotic agents currently under early-phase investigation.Combining different mechanisms of action may offer synergy, but randomized trials are required.An integrated approach including early diagnosis, pharmacological optimization, rehabilitation and multidisciplinary care is essential to improve quality of life and long-term outcomes.

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