Heart failure with reduced ejection fraction

Disease Description (Causes and Symptoms)

• Definition: Heart failure with preserved ejection fraction (HFpEF) is defined as a condition in which the left ventricular ejection fraction (LVEF) is preserved at 50% or higher, while symptoms or signs of heart failure are present and there is objective evidence of functional or structural cardiac abnormalities, such as elevated natriuretic peptides (BNP/NT‑proBNP) or left ventricular diastolic dysfunction/elevated filling pressure.
• Major causes and pathophysiology:
  • Common contributing factors include hypertension, age-related myocardial fibrosis and left ventricular hypertrophy, coronary artery disease, atrial fibrillation, diabetes mellitus, chronic kidney disease, and obesity.
  • Systemic inflammation and metabolic abnormalities, along with vascular and endothelial dysfunction, reduce left ventricular relaxation and compliance and increase filling pressure, causing a sharp rise in pulmonary capillary pressure during exercise. This is the primary mechanism.
• Major symptoms:
  • Shortness of breath during activity (exercise), easy fatigue (exercise intolerance)
  • Orthopnea (worsening shortness of breath when lying down), paroxysmal nocturnal dyspnea
  • Lower-extremity edema, weight gain, tachycardia or palpitations (when accompanied by an arrhythmia)
• Differential diagnosis: Similar symptoms may also occur with lung disease, anemia, obesity, thyroid disease, and other conditions, so differential diagnosis is necessary.

Treatment Methods

• Goals: Relief of symptoms, improvement of exercise capacity, reduction of hospitalizations due to worsening heart failure, and treatment of comorbidities
• Drug treatment (reflecting recent recommendations)
  • Diuretics: Used based on symptoms to control congestion (edema, shortness of breath). Monitoring of kidney function and electrolytes is necessary.
  • SGLT2 inhibitors (e.g., empagliflozin, dapagliflozin): Their benefits, including a reduction in heart-failure-related hospitalizations, have been demonstrated in HFpEF, so their indications should be considered.
  • MRAs (such as spironolactone): May reduce the risk of hospitalization in some patients; monitoring of kidney function and potassium is required.
  • ARNI (sacubitril/valsartan), ARBs, ACE inhibitors, beta-blockers: Survival benefits in HFpEF are not consistent. However, they are used as indicated according to comorbidities such as hypertension, ischemic heart disease, and arrhythmias.
  • Antiarrhythmic drugs and anticoagulants: When atrial fibrillation is present, appropriate anticoagulation (according to CHA2DS2‑VASc) and heart-rate control are necessary.
• Nonpharmacological treatment
  • Weight loss, regular aerobic exercise (a cardiac rehabilitation program is recommended), diet (low sodium), smoking cessation, and moderation of alcohol consumption
  • Individualized control of fluid and salt intake
• Procedural and surgical approaches
  • If coronary ischemia is the underlying mechanism, reperfusion and revascularization should be considered.
  • For arrhythmias (e.g., therapeutic catheter ablation and atrial fibrillation management), appropriate procedures should be performed.
  • Left ventricular assist devices and transplantation generally have more limited indications than in HFrEF.
• Precautions (points to note during treatment)
  • Excessive use of diuretics may cause hypotension, worsening kidney function, and electrolyte abnormalities → Dose adjustment and kidney function tests are necessary.
  • Be cautious of hyperkalemia when using MRAs.
  • When using SGLT2 inhibitors, monitor for urinary tract infections, genital infections, and changes in fluid volume.
  • Active evaluation and treatment of comorbidities such as obesity, lung disease, and anemia are important.

Checkpoints Before an Outpatient Visit (Including Items to Bring and Sample Questions)

• Items to bring (recommended)
  • A list of all medications currently being taken (including directions and doses) or photos of the medication bags
  • Copies of recent test results (echocardiography report, BNP/NT‑proBNP levels, blood tests, chest X-ray, electrocardiogram, etc.)
  • Records of changes in weight, blood pressure, and symptoms (if possible, over several weeks)
  • Examples of situations in which symptoms worsen or activities that cause shortness of breath during exercise (how far you can walk, stairs, etc.)
  • Allergy information and records of previous surgeries and hospitalizations
• Information to tell the medical staff in advance during the outpatient visit
  • Recent rapid weight gain (2 kg or more within 48–72 hours)
  • If shortness of breath has limited your activities
  • Accompanying symptoms such as cough, fever, chest pain, or fainting
• Materials to show the doctor during the outpatient visit
  • Recent echocardiography images/report, BNP level, and a list of medications currently being taken, such as blood-pressure and diabetes medications

General Sample Questions to Ask the Doctor

• "What are the treatment goals for this condition? What changes can I expect in the short and long term?"
• "What are the main side effects and precautions of the medications I am taking?"
• "If my symptoms worsen, when should I go to the emergency room? What are the signs that hospitalization is needed?"
• "What specifically should I do regarding lifestyle habits (exercise, diet, and weight management)? What is the recommended amount of exercise?"

Condition-Specific Sample Questions

• "My latest echocardiogram shows an EF of 50% or higher, but I still have shortness of breath. Do I need a BNP test or any additional tests? (e.g., an exercise stress test or invasive hemodynamic testing)"
• "Is an SGLT2 inhibitor (or spironolactone, etc.) appropriate for me? What benefits can I expect, and which tests should be monitored?"