Heart failure with preserved ejection fraction (HFpEF), also known as diastolic heart failure, occurs when the heart muscle stiffens and cannot relax properly between beats. This prevents the ventricles—the two lower chambers that pump blood out of the heart—from filling with enough blood, even though the heart’s pumping ability (ejection fraction) remains normal.
When the ventricles cannot fill efficiently, less oxygen-rich blood circulates throughout the body. Over time, this may lead to fatigue, fluid buildup and breathing difficulties. Understanding HFpEF is key to recognizing early symptoms, managing risk factors and maintaining a healthy heart for life.
Because the signs of HFpEF can be subtle and mistaken for other conditions, many people live with the condition for years before being diagnosed. Identifying HFpEF early can allow for prompt treatment to support heart relaxation, manage blood pressure and prevent fluid overload.
Without treatment, heart failure with preserved ejection fraction can worsen over time, increasing the risk of complications, such as pulmonary hypertension, irregular heart rhythms (arrhythmias) and chronic heart failure. A prompt diagnosis and appropriate lifestyle adjustments can significantly improve the long-term outcome and quality of life.
What Are the Types of Heart Failure With Preserved Ejection Fraction?
HFpEF is not a single condition but rather a group of related disorders that affect how the heart fills and relaxes. Each type has a distinct cause, but all share the same underlying issue: The heart is unable to fill with blood efficiently despite a normal pumping strength.
The primary forms of heart failure with preserved ejection fraction are:
- Hypertensive HFpEF – Caused by long-term high blood pressure (hypertension), which thickens and stiffens the heart muscle, reducing its flexibility
- Ischemic HFpEF – Develops when coronary artery disease restricts blood flow, damaging the heart muscle over time
- Infiltrative or restrictive HFpEF – Results from an underlying heart condition, such as amyloidosis or sarcoidosis, in which abnormal proteins or cells infiltrate the heart tissue
- Valvular HFpEF – Occurs when heart valve disease, such as aortic stenosis or mitral regurgitation, creates pressure overload on the heart, limiting its ability to fill
In many cases, HFpEF involves overlapping factors, particularly when hypertension, obesity or diabetes are also present. Understanding its type can guide targeted therapy and improve heart performance.
What Are the Causes and Risk Factors for Heart Failure With Preserved Ejection Fraction?
HFpEF often develops gradually as the heart muscle thickens and stiffens over time. Usually, the condition stems from a combination of physical stressors and lifestyle factors that weaken the heart.
Several underlying medical conditions can contribute to heart failure with preserved ejection fraction. These include:
- High blood pressure – The most common cause of HFpEF is hypertension, which causes chronic pressure overload that forces the heart to work harder and thickens its walls.
- Coronary artery disease – Reduced oxygen supply can damage the heart tissue and limit its flexibility.
- Atrial fibrillation (AFib) – Irregular heart rhythms can interfere with normal ventricle filling.
- Inflammation – A heart infection, such as endocarditis, may cause stiffness or scarring in the heart tissue.
- Metabolic disorders – Obesity and diabetes alter how the heart muscle processes energy, potentially leading to stiffness.
Certain traits and behaviors can increase the likelihood of developing heart failure with preserved ejection fraction. These include:
- Advanced age – The risk of heart disease increases with age, especially after 60.
- Gender – Women are more frequently affected by HFpEF than men, particularly after menopause.
- Lifestyle factors – Unhealthy habits that can contribute to the risk of HFpEF include smoking, long-term alcohol consumption, lack of physical activity, chronic stress, insufficient sleep and a diet high in salt, sugar or processed foods.
- Certain coexisting conditions – Hypertension, high cholesterol, diabetes, kidney disease, lung disease and sleep apnea have all been linked to HFpEF.
Genetics can also influence the development of heart failure with preserved ejection fraction, as some people inherit traits that can affect the formation or function of the heart muscle. Hereditary risk factors for HFpEF include:
- Family history of heart failure or cardiomyopathy
- Inherited conditions that alter cholesterol or metabolic processes, such as familial hypercholesterolemia (FH) and Smith-Lemli-Opitz syndrome (SLOS)
What Are the Warning Signs and Symptoms of Heart Failure With Preserved Ejection Fraction?
HFpEF symptoms typically develop slowly and may worsen with time as the heart becomes unable to handle increases in blood volume or pressure, especially during physical exertion. While the symptoms can vary from person to person, the most frequently reported signs include:
- Shortness of breath – Often occurs during exercise or when lying flat due to fluid buildup in the lungs
- Cough or wheezing – Especially when lying down at night
- Fatigue or weakness – Results from reduced oxygen delivery to the muscles
- Swelling (edema) – May become noticeable in the legs, ankles or abdomen as the body retains fluid
- Rapid weight gain – May signal fluid accumulation
- Heart palpitations – A sensation of fluttering or irregular heartbeat
The severity of the symptoms typically corresponds to the extent of impairment in the heart’s ability to fill properly. General patterns include:
- Mild cases – Symptoms appear only with physical exertion, such as climbing stairs or exercising.
- Moderate to severe cases – Shortness of breath, fatigue or edema may occur, even during rest or sleep.
- Silent or asymptomatic cases – Few noticeable symptoms develop until the heart strain leads to hospitalization or an acute event.
Anyone experiencing signs of HFpEF, such as persistent shortness of breath, edema or unexplained tiredness, should consult a physician. Additionally, it is crucial to seek emergency medical attention for potentially life-threatening symptoms, such as sudden chest pain or tightness, fainting or confusion, severe shortness of breath or rapid heartbeat.
How Is Heart Failure With Preserved Ejection Fraction Diagnosed?
The diagnostic process for HFpEF typically involves a thorough clinical assessment and specialized imaging.
Initial Evaluation and Medical History
Diagnosing heart failure with preserved ejection fraction begins with a thorough review of the patient’s medical history, symptoms and lifestyle. During this evaluation, the physician will ask about possible contributing factors, such as hypertension, diabetes, sleep apnea and other conditions that can cause the heart muscle to stiffen. The physician will also perform a physical examination to check for signs of fluid buildup, irregular heartbeat or swelling in the legs or abdomen.
This initial evaluation is particularly important because heart failure with preserved ejection fraction may not cause clear abnormalities on standard cardiac tests, such as electrocardiogram (EKG), stress test and coronary angiogram, which are mainly designed to identify blocked arteries or a weakened pumping function. HFpEF occurs when the heart muscle stiffens, affecting its ability to relax and fill properly with blood. For this reason, specialized imaging is often necessary to help the physician assess how well the heart relaxes and fills.
Common Diagnostic Tests for Heart Failure With Preserved Ejection Fraction
To confirm a diagnosis of HFpEF, the physician may recommend testing to evaluate the structure and function of the heart. Options may include:
- Echocardiogram – Measures how well the heart relaxes between beats and can be used to confirm preserved ejection fraction
- Electrocardiogram – Records the heart’s electrical activity and can detect rhythm problems
- Blood work – Can identify heart failure biomarkers (BNP or NT-proBNP), measure kidney function and check for electrolyte imbalances
- Stress test – Shows how the heart responds to exercise or medications that simulate physical exertion
- Cardiac magnetic resonance imaging (MRI) or computed tomography (CT) scans – Provide detailed images of the heart’s walls, valves and chambers
- Right heart catheterization – Measures the pressure inside the heart to confirm stiffness or abnormal filling
Differential Diagnosis for Symptoms of Heart Failure With Preserved Ejection Fraction
Because HFpEF shares symptoms with many other conditions, the physician may order additional tests to rule out other possible causes of shortness of breath, fatigue or fluid buildup, such as:
- Coronary artery blockages – Tests such as a coronary angiogram, stress test or cardiac CT scan can help the physician determine whether narrowed or blocked arteries are limiting blood flow to the heart.
- Pulmonary hypertension – An echocardiogram or right heart catheterization may be performed to measure pressure in the lungs’ blood vessels and assess how the right side of the heart is functioning.
- Lung disease – Chest X-rays, CT scans and pulmonary function tests can help the physician identify chronic lung conditions that may cause symptoms similar to those of HFpEF.
- Heart valve disorders – A comprehensive echocardiogram can help the physician evaluate whether the heart valves are leaking or narrowed, which can affect blood flow and mimic heart failure symptoms.
- Pericardial disease (inflammation around the heart) – Echocardiography, cardiac MRI or CT imaging can help the physician detect inflammation or fluid buildup in the sac surrounding the heart.
How Is Heart Failure With Preserved Ejection Fraction Treated?
HFpEF treatment aims to reduce symptoms, promote heart relaxation and prevent disease progression. The optimal approach can vary based on the underlying cause and the patient’s overall health.
Medications for Managing Heart Failure With Preserved Ejection Fraction
Medications can help reduce fluid buildup, control blood pressure and improve heart efficiency. Commonly prescribed drugs for HFpEF include:
- Diuretics – Can relieve swelling and fluid accumulation in the lungs or legs
- Angiotensin-converting-enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs) or beta-blockers – Can relax blood vessels, reduce strain on the heart and help the ventricles fill more efficiently
- Aldosterone antagonists – Can limit sodium retention and prevent further thickening of the heart muscle
- SGLT2 inhibitors – Can improve the heart’s energy use and avoid hospitalizations
- Anticoagulants – May be considered for a patient with AFib to help prevent clot formation
Lifestyle Changes for Managing Heart Failure With Preserved Ejection Fraction
Healthy habits can play a major role in controlling HFpEF symptoms and improving the long-term outcome. Most patients are encouraged to:
- Eat a balanced, low-sodium diet – Focus on whole grains, fruits, vegetables and lean proteins.
- Exercise regularly – Engage in light to moderate activity under medical supervision.
- Maintain a healthy body weight – Lose excess pounds to reduce the strain on the heart.
- Quit tobacco – Stop smoking to improve circulation and lung function.
- Manage stress – Practice relaxation techniques, such as meditation or yoga.
Surgical and Procedural Interventions for Heart Failure With Preserved Ejection Fraction
A surgical or procedural intervention may be considered if another heart condition is contributing to HFpEF symptoms and medication-based treatment alone is insufficient. Options may include:
- Valve repair or replacement – Can restore normal blood flow in a case of valvular disease
- Catheter ablation – Can correct AFib and other irregular heart rhythms
- Pacemaker or defibrillator – Can help regulate heart rhythms and support coordinated contractions
Ongoing Care and Management of Heart Failure With Preserved Ejection Fraction
Because HFpEF is a chronic condition, continued monitoring is essential to maintain stability and prevent flare-ups. This may involve:
- Regular cardiology visits for medication adjustments as needed
- Participation in cardiac rehabilitation programs
- Daily tracking of weight and swelling
- Counseling or support groups for long-term motivation and education
What Are the Complications and Long-Term Effects of Heart Failure With Preserved Ejection Fraction?
Even with preserved pumping function, HFpEF can still lead to serious long-term health concerns resulting from increased pressure in the heart and lungs or damage to other organs. Possible complications include:
- Recurrent fluid retention
- Pulmonary hypertension
- Kidney impairment
- Irregular heart rhythms
- Decreased capacity for physical activity
Lifelong management of HFpEF is often required to help minimize risks, prevent disease progression and maintain comfort and daily function. Chronic health impacts may include:
- Persistent fatigue and reduced exercise tolerance
- Swelling or fluid accumulation
- Episodes of shortness of breath with mild exertion
To manage these effects, it is important to:
- Take medications as prescribed
- Monitor weight daily for fluid changes
- Follow a low-sodium diet
- Contact the physician promptly if symptoms worsen
Can Heart Failure With Preserved Ejection Fraction Be Prevented?
While not all cases of HFpEF can be prevented, positive lifestyle choices and early medical intervention greatly reduce the risk.
Lifestyle Modifications to Help Prevent Heart Failure With Preserved Ejection Fraction
Healthy living is the most effective way to reduce the risk of developing HFpEF and other heart diseases. In general, this involves:
- Eating a diet rich in fruits, vegetables, lean proteins and whole grains
- Exercising regularly to maintain heart and lung function
- Avoiding tobacco and limiting alcohol consumption
- Managing blood pressure, cholesterol and diabetes
- Maintaining a healthy body weight
Regular Screenings and Monitoring to Help Prevent Heart Failure With Preserved Ejection Fraction
Routine medical checkups can help detect heart issues before symptoms appear. Regular monitoring can allow for early intervention when needed and lead to effective management.
Preventive Medications and Vaccinations to Help Prevent Heart Failure With Preserved Ejection Fraction
Certain medications and vaccines may be recommended to protect heart health and reduce secondary risks. Options may include:
- Blood pressure and cholesterol medications to control key heart disease risk factors
- Antibiotics before dental and surgical procedures if heart valve disease is present
- Influenza (flu) and pneumonia vaccines to reduce respiratory infections that strain the heart
What Is It Like to Live With Heart Failure With Preserved Ejection Fraction?
HFpEF requires consistent care and self-awareness, but with proper management, most patients maintain an active, independent lifestyle.
Daily Adjustments for Living With Heart Failure With Preserved Ejection Fraction
Some simple lifestyle adjustments can help the patient manage symptoms and maintain stability. Potentially effective strategies include:
- Following dietary recommendations
- Taking prescribed medications
- Staying active with physician-approved exercise
- Getting adequate rest and managing stress levels
- Monitoring for swelling or breathing changes
Support Systems and Resources for Living With Heart Failure With Preserved Ejection Fraction
Emotional and educational support can play a key role in the successful management of HFpEF. Options may include:
- Joining a cardiac rehabilitation program for guided exercise and education
- Connecting with support groups for shared experiences and motivation
- Seeking counseling to manage any emotional or lifestyle challenges
The Impact of Heart Failure With Preserved Ejection Fraction on Mental Health
Because living with a chronic heart condition can affect emotional well-being, it may be helpful for the patient to:
- Practice relaxation techniques, such as meditation or breathing exercises
- Stay socially connected with friends and family
- Reach out to a healthcare provider when feeling anxious or depressed
Benefit From World-Class Care at Tampa General Hospital
Heart failure with preserved ejection fraction is a complex but manageable condition. With an early diagnosis, positive lifestyle changes and expert medical care, most patients can live well and minimize the long-term risks.
At TGH’s renowned Heart and Vascular Institute, our patients receive world-class care from a multidisciplinary team specializing in advanced cardiac diagnostics and treatment. Our program is recognized among the nation’s best for cardiovascular excellence and patient outcomes.
If you are experiencing symptoms of HFpEF, such as shortness of breath, leg swelling or fatigue, don’t wait to seek care. Request an appointment with a TGH cardiologist today to begin your path toward better heart health and lasting wellness.