Heart failure with preserved ejection fraction (HFpEF) in older adults

The NHS says heart failure is when the heart cannot pump blood properly, and stresses it does not mean the heart has stopped or is about to stop. The BHF explains that doctors talk about "ejection fraction", the percentage of blood squeezed out of the main chamber with each beat, measured from an echocardiogram. Heart failure is grouped into HFpEF (50% or more), HFmrEF (40% to 49%) and HFrEF (40% or less).

In HFpEF, the number looks normal, but the heart can still fail to meet the body's needs, so symptoms of heart failure occur. The NHS says the type relates to why the heart is not pumping as well as it should, while the stage explains how severe symptoms are. The BHF describes four stages from no symptoms in everyday activity (stage 1) to symptoms even at rest (stage 4).

The NHS lists breathlessness during everyday activity or when lying down, feeling weak, light-headed or very tired, swelling in the feet, ankles, legs or tummy, feeling bloated, sudden weight gain, coughing at night and coughing up frothy pink phlegm. The BHF mentions fainting, fatigue at rest that worsens with movement, and swelling that can spread to the lower body.

In an older person these may be mistaken for ordinary ageing, a chest infection or reduced fitness. Being more breathless than expected for the activity, needing extra pillows, or gradual ankle swelling is worth a GP appointment.

The NHS says to see a GP if you have symptoms of heart failure. It says to ask for an urgent GP appointment or get help from NHS 111 if you feel breathless lying down or from everyday activity, are coughing up frothy pink phlegm, or have suddenly gained weight. It says to call 999 if you have severe difficulty breathing (gasping, choking or unable to get words out), lips or skin that are pale, blue or grey, or someone has passed out and is not responding normally. Do not drive yourself to A&E.

The BHF lists a heart attack, cardiomyopathy and high blood pressure as the most common causes, with other causes including abnormal heart rhythms, amyloidosis, anaemia, congenital conditions, heart valve disease, pulmonary hypertension, some cancer treatments, thyroid problems and too much alcohol. The NHS adds chronic kidney disease and haemochromatosis, and says you may be more at risk if you are 65 or older, overweight or obese, smoke, drink heavily or use cocaine.

The BHF says a stiff heart syndrome called cardiac amyloidosis can lead to heart failure. Several of these causes are also common in older adults, which is why blood pressure, kidney function and thyroid tests are often part of the work-up.

The BHF says the doctor asks about medical history, symptoms and examination, then may arrange a 24-hour ECG, a chest X-ray to check for fluid in the lungs, 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 see if a lung problem is causing breathlessness. The NHS adds blood and urine samples, MRI scans and peak flow or spirometry, and referral to a cardiologist. Some tests may need a hospital visit.

The NHS says treatment depends on type, stage and overall health and aims to ease symptoms and prevent worsening. Medicines include diuretics such as furosemide to reduce fluid build-up, medicines that widen blood vessels so the heart works less hard (for example candesartan or enalapril) and beta blockers that slow the heart. Surgery may be needed to improve blood flow, repair or replace valves, or fit a pacemaker or ICD. Severe cases may be offered a left ventricular assist device or transplant. The BHF adds that watching how much fluid you drink may be recommended by the team.

Self-care steps from the NHS include taking medicines as prescribed, weighing yourself regularly, having flu and other offered vaccinations, staying active after a cardiac rehabilitation assessment, eating a balanced diet, keeping a healthy weight, stopping smoking and cutting down on alcohol. The BHF recommends staying below 14 units of alcohol a week. Because diuretics and blood pressure medicines can cause dizziness and low blood pressure in older people, report any new light-headedness or falls to the team rather than stopping tablets yourself.

The NHS says symptoms vary from day to day and week to week, and the condition can be kept stable for many years. You may need to adapt work, and tell the DVLA if you drive. As part of treatment you should be referred to a palliative care or symptom control team, which focuses on quality of life for any lifelong incurable illness. The BHF notes that conversations about life expectancy are difficult, and that sorting out care, finances and Wills when feeling well can give peace of mind. It also notes anxiety is common, and the NHS says you can refer yourself to an NHS talking therapies service.