Heart failure with preserved ejection fraction (HFpEF): what it means and how it is managed

The NHS describes heart failure as the heart being unable to pump blood properly. It does not mean the heart has stopped working or is about to stop. There are different types, and doctors group them using the ejection fraction, which the British Heart Foundation (BHF) explains is the amount of blood squeezed out of the main chamber of the heart with each beat. It is usually measured as a percentage and over 50% is considered normal.

The BHF says that, depending on the percentage and other tests, heart failure may be classed as heart failure with preserved ejection fraction (HFpEF) at 50% or more, heart failure with mildly reduced ejection fraction (HFmrEF) at 40% to 49%, or heart failure with reduced ejection fraction (HFrEF) at 40% or less. In HFpEF, therefore, the heart still ejects a normal proportion of its blood, but the person has symptoms and signs of heart failure.

The label matters because treatment depends on the type and stage. NICE guideline NG106 covers diagnosing and managing chronic heart failure in adults and has separate recommendations for treating heart failure with reduced ejection fraction and for heart failure with mildly reduced or preserved ejection fraction.

The NHS lists feeling out of breath during everyday activities or lying down, being more out of breath than expected during physical activity, feeling weak, light-headed or very tired, swelling in the feet, ankles, legs or tummy or feeling bloated, sudden weight gain, coughing at night and coughing up frothy pink phlegm. The symptoms vary from day to day and week to week.

The BHF explains that sudden weight gain can result from fluid building up in the body because the heart is not working properly, which is why regular weighing is recommended.

• See a GP if you have symptoms of heart failure, according to the NHS.

• Ask for an urgent GP appointment or get help from NHS 111 if you feel breathless when lying down or from everyday activity, you are coughing up frothy pink phlegm, or you have suddenly gained weight.

• Call 999 if you have severe difficulty breathing (gasping, choking or not able to get words out), your lips or skin are pale, blue or grey, or someone has passed out and is not responding normally. Do not drive yourself to A&E.

The NHS says there are lots of possible causes. Heart failure can happen suddenly, for example after a heart attack or infection, or from long-term strain on the heart from high blood pressure or coronary heart disease. Other causes include heart valve disease, cardiomyopathy, heart rhythm problems, chronic kidney disease, anaemia, haemochromatosis and thyroid problems.

Anyone can get heart failure, but the NHS says you may be more at risk if you are 65 or older, are living with overweight or obesity, are pregnant, smoke, drink a lot of alcohol or use cocaine. The BHF also lists some cancer treatments, an underactive or overactive thyroid gland and drinking more than 14 units of alcohol a week among the factors that can contribute.

The BHF says your doctor will ask about your medical history and symptoms and examine you, then arrange tests. These may include a 24-hour ECG, a chest X-ray to look for fluid in the lungs or a lung condition, an echocardiogram to see how the heart is working, blood tests including BNP, a protein that is higher when the heart is not working as it should, and breathing tests to check for a lung problem causing breathlessness.

The NHS adds that tests may include samples of blood and pee, scans such as MRI, and tests of lung function, and that you may be referred to a heart specialist (cardiologist). The echocardiogram is particularly important in HFpEF because it is how the ejection fraction is measured.

The NHS says there is currently no cure for heart failure, but treatment aims to ease symptoms and help prevent the condition getting worse, and depends on the type and stage of heart failure and your overall health. Medicines may be used to make you pee more to reduce fluid build-up (diuretics such as furosemide), widen blood vessels so the heart does not need to work as hard, or slow the heart down (beta blockers).

Surgery or devices may be needed in some people, for example to improve blood flow, repair or replace heart valves, or fit a pacemaker or implantable cardioverter defibrillator (ICD). Cardiac rehabilitation is offered to everyone with heart failure and may include an exercise assessment, exercise classes, and support with lifestyle changes.

The BHF suggests keeping active, which has been shown to boost energy and improve sleep and quality of life, keeping to a healthy weight and diet, keeping alcohol under the recommended 14 units a week, stopping smoking, watching how much fluid you drink if recommended, and weighing yourself regularly because sudden weight gain may mean too much fluid is building up.

Heart failure affects everyone differently, and the NHS says treatment and lifestyle changes can help keep it stable for many years. The BHF acknowledges that there is no cure, which can be upsetting, and that it is very difficult to live with uncertainty. It suggests talking to a GP or specialist heart failure team about what to expect, and discussing worries with family, friends and the heart failure team.

The BHF stages heart failure from stage 1, where there are no symptoms during everyday activity, to stage 4, where you cannot do any physical activity without symptoms and may feel uncomfortable at rest. Your doctor may tell you which stage applies, and this helps decide treatment.

On the NHS, a GP can arrange blood tests and an echocardiogram and refer to a cardiologist or specialist heart failure team, who coordinate medicines, cardiac rehabilitation and monitoring. This care is free at the point of use, and NICE guideline NG106 sets out what is recommended.

Some people choose a private cardiology consultation or echocardiogram for faster access. The ejection fraction measured on a private scan is the same measure, so sharing the report with your NHS team helps avoid repeating tests.