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HFPEF

Management of HFPEF

Last updated 23 Mar 2026 · Heart Failure

Introduction & Australian Epidemiology

Heart failure with preserved ejection fraction (HFpEF) represents a complex clinical syndrome characterised by symptoms and signs of heart failure in the presence of normal or near-normal left ventricular ejection fraction (≥50%). Previously termed "diastolic heart failure," HFpEF is now recognised as a distinct pathophysiological entity with significant morbidity and mortality implications for the Australian population.

ℹ️
Definition: HFpEF is diagnosed when patients present with heart failure symptoms and signs, LVEF ≥50%, elevated natriuretic peptides, and evidence of structural heart disease or diastolic dysfunction.

Australian Epidemiology

HFpEF accounts for approximately 50-60% of all heart failure cases in Australia, with prevalence increasing with age. The condition predominantly affects older adults, with a mean age at diagnosis of 75-80 years. Key epidemiological features in the Australian context include:

  • Prevalence: Estimated 1.5-2% of the general Australian population, rising to 10-15% in those aged >80 years
  • Gender distribution: Slight female predominance (55-60%), particularly in older age groups
  • Geographic variation: Higher prevalence in rural and remote areas, with limited access to specialist cardiac services
  • Comorbidity burden: High prevalence of diabetes (40-50%), hypertension (80-90%), atrial fibrillation (40-60%), and obesity (60-70%)
  • Healthcare utilisation: Accounts for >100,000 hospitalisations annually, with 30-day readmission rates of 15-20%
Key Statistics
  • 5-year mortality: 50-60%
  • Annual hospitalisation rate: 25-30%
  • Healthcare cost: $2.5-3 billion annually
  • Projected 25% increase by 2030
Risk Factors
  • Advanced age (>65 years)
  • Hypertension
  • Diabetes mellitus
  • Obesity (BMI >30 kg/m²)
  • Atrial fibrillation
  • Chronic kidney disease

Aboriginal and Torres Strait Islander Populations

HFpEF occurs 2-3 times more frequently in Aboriginal and Torres Strait Islander populations, with earlier onset (mean age 10-15 years younger) and higher rates of comorbidities including diabetes, chronic kidney disease, and rheumatic heart disease. Geographic isolation and limited healthcare access contribute to delayed diagnosis and suboptimal management.

⚠️
Diagnostic Challenge: HFpEF is frequently underdiagnosed in primary care settings, with symptoms often attributed to normal aging or deconditioning. High index of suspicion required in elderly patients with dyspnoea and preserved LVEF.

Healthcare System Impact

The burden of HFpEF on the Australian healthcare system is substantial and growing. Unlike heart failure with reduced ejection fraction (HFrEF), therapeutic options for HFpEF remain limited, with management primarily focused on symptom control and comorbidity management. This presents unique challenges for:

  • Primary care: Early recognition and appropriate referral pathways
  • Emergency departments: Acute management and appropriate disposition
  • Cardiology services: Specialised assessment and long-term management
  • Aged care facilities: Managing complex, frail patients with multiple comorbidities

This guideline provides evidence-based recommendations aligned with Australian clinical practice standards, Medicare Benefits Schedule (MBS) provisions, and Pharmaceutical Benefits Scheme (PBS) listings to optimise care delivery across all healthcare settings.

Pathophysiology

Heart failure with preserved ejection fraction (HFpEF) represents a complex pathophysiological syndrome characterised by abnormal left ventricular diastolic function with maintained systolic contractility. The condition results from multiple interconnected mechanisms that impair cardiac filling and reduce functional capacity.

Primary Mechanisms

1
Diastolic Dysfunction
Impaired left ventricular relaxation (lusitropy) and increased chamber stiffness leading to elevated filling pressures despite normal ejection fraction (≥50%). Results from altered calcium handling, increased myocardial fibrosis, and cardiomyocyte hypertrophy.
2
Left Atrial Dysfunction
Progressive left atrial enlargement and dysfunction due to chronic pressure overload. Contributes to atrial fibrillation development and further impairs ventricular filling through loss of atrial contribution to cardiac output.
3
Chronotropic Incompetence
Impaired heart rate response to exercise stress, limiting cardiac output augmentation during physical activity. Often associated with sinus node dysfunction and autonomic imbalance.
4
Pulmonary Vascular Changes
Development of pulmonary hypertension due to elevated left atrial pressures, leading to right heart dysfunction and exercise intolerance. May progress to combined pre- and post-capillary pulmonary hypertension.

Molecular and Cellular Mechanisms

Myocardial Fibrosis
  • Increased collagen deposition and cross-linking
  • Activated myofibroblasts and inflammatory pathways
  • Transforming growth factor-β (TGF-β) upregulation
  • Galectin-3 and matrix metalloproteinase dysregulation
Cardiomyocyte Abnormalities
  • Altered calcium handling proteins (SERCA2a, phospholamban)
  • Increased resting tension from titin modifications
  • Mitochondrial dysfunction and oxidative stress
  • Impaired nitric oxide-cGMP-protein kinase G pathway

Systemic Contributing Factors

ℹ️
Multi-system Involvement: HFpEF is increasingly recognised as a systemic disorder with contributions from multiple organ systems beyond the heart.
System Pathophysiological Changes Clinical Impact
Vascular Arterial stiffening, endothelial dysfunction, increased afterload Elevated systolic BP, reduced coronary flow reserve
Renal Reduced glomerular filtration, sodium retention, RAAS activation Volume overload, electrolyte imbalance, worsening congestion
Metabolic Insulin resistance, altered substrate utilisation, inflammation Diabetes risk, obesity, dyslipidaemia, systemic inflammation
Skeletal Muscle Reduced oxidative capacity, muscle atrophy, impaired oxygen extraction Exercise intolerance, frailty, reduced functional capacity
Autonomic Sympathetic activation, parasympathetic withdrawal Chronotropic incompetence, arrhythmias, hypertension

Phenotypic Heterogeneity

HFpEF encompasses multiple distinct phenotypes with varying dominant pathophysiological mechanisms:

Phenotype 1
Hypertensive-Metabolic
Predominantly elderly females with hypertension, diabetes, obesity. Characterised by concentric remodelling and metabolic dysfunction.
Phenotype 2
Ischaemic-Fibrotic
Coronary artery disease with extensive myocardial fibrosis. More prevalent in males with prior myocardial infarction.
Phenotype 3
Atrial Fibrillation-Associated
Prominent atrial dysfunction with recurrent or persistent atrial fibrillation. Significant chronotropic incompetence.
⚠️
Clinical Implication: The heterogeneous pathophysiology of HFpEF explains the variable response to therapeutic interventions and emphasises the need for personalised treatment approaches based on dominant phenotypic characteristics.

Exercise Physiology in HFpEF

Exercise intolerance in HFpEF results from the interaction of multiple mechanisms:

  • Impaired Frank-Starling Mechanism: Steep end-diastolic pressure-volume relationship limits preload reserve
  • Chronotropic Incompetence: Inadequate heart rate response limits cardiac output augmentation
  • Pulmonary Vascular Dysfunction: Elevated pulmonary pressures during exercise cause dyspnoea
  • Peripheral Limitations: Reduced skeletal muscle oxidative capacity and oxygen extraction
  • Arterioventricular Coupling: Mismatch between ventricular and arterial properties reduces efficiency
✅
Key Concept: Understanding the multi-factorial pathophysiology of HFpEF is essential for appropriate diagnostic evaluation, risk stratification, and targeted therapeutic interventions in Australian clinical practice.

Clinical Presentation & Diagnostic Criteria

Core Clinical Features

Heart failure with preserved ejection fraction (HFpEF) presents with typical heart failure symptoms despite normal or near-normal left ventricular ejection fraction (≥50%). The diagnosis requires the presence of heart failure signs and symptoms, evidence of elevated cardiac pressures, and preserved systolic function.

⚠️
Key Diagnostic Challenge: HFpEF symptoms are often non-specific and may be attributed to other conditions, particularly in elderly patients. High index of suspicion required in at-risk populations.

Presenting Symptoms

  • Dyspnoea on exertion - Most common presenting symptom (>90% of patients)
  • Exercise intolerance - Reduced functional capacity, fatigue with minimal activity
  • Orthopnoea - Difficulty breathing when lying flat
  • Paroxysmal nocturnal dyspnoea - Awakening with breathlessness
  • Lower limb oedema - Bilateral ankle swelling, may progress proximally
  • Chest discomfort - Non-specific chest pressure or tightness
  • Palpitations - Often associated with atrial fibrillation
  • Cognitive impairment - Confusion, memory problems (particularly in elderly)

Physical Examination Findings

Cardiovascular Signs
  • Elevated jugular venous pressure (JVP)
  • Third heart sound (S3 gallop) - less common than in HFrEF
  • Fourth heart sound (S4) - more common in HFpEF
  • Mitral or tricuspid regurgitation murmur
  • Laterally displaced apex beat
  • Irregular pulse (atrial fibrillation in 65% of patients)
Pulmonary & Systemic Signs
  • Fine bibasal inspiratory crackles
  • Pleural effusion (usually bilateral)
  • Pitting oedema (ankles, legs, sacrum)
  • Hepatomegaly and hepatojugular reflux
  • Ascites (in severe cases)
  • Cool peripheries, prolonged capillary refill
ℹ️
Clinical Pearl: HFpEF patients often have fewer overt signs of congestion compared to HFrEF, but elevated filling pressures are still present. Normal examination does not exclude HFpEF.

Diagnostic Criteria for HFpEF

The diagnosis requires all three criteria to be met:

1
Heart Failure Symptoms & Signs
Typical symptoms (dyspnoea, fatigue, exercise intolerance) and/or signs (elevated JVP, pulmonary congestion, peripheral oedema)
2
Preserved Ejection Fraction
Left ventricular ejection fraction (LVEF) ≥50% on echocardiography
3
Evidence of Elevated Filling Pressures
Elevated natriuretic peptides AND/OR echocardiographic evidence of diastolic dysfunction AND/OR invasive haemodynamic evidence

HFA-PEFF Diagnostic Algorithm

The Heart Failure Association Pre-test assessment, Echocardiography & natriuretic peptides, Functional testing, Final etiology (HFA-PEFF) algorithm provides a structured diagnostic approach:

Step Component Criteria Points
P1: Pre-test Heart failure symptoms Typical symptoms + clinical context Required
Preserved LVEF LVEF ≥50% Required
No obvious cause Excluding other causes of dyspnoea Required
P2: Echo & BNP Natriuretic peptides BNP ≥35 pg/mL or NT-proBNP ≥125 pg/mL 2 points
Echocardiographic criteria See detailed echo scoring below 0-6 points
P3: Functional Diastolic stress test If P2 score intermediate (2-4 points) Confirmatory
✅
HFA-PEFF Scoring: ≥5 points = HFpEF confirmed; 2-4 points = intermediate (consider functional testing); 0-1 points = HFpEF unlikely.

Echocardiographic Criteria (HFA-PEFF P2)

Parameter Abnormal Values Points
Septal e' velocity <7 cm/s 1 point
Lateral e' velocity <10 cm/s 1 point
E/e' ratio (average) >15 2 points
E/e' ratio (average) 9-15 1 point
Left atrial volume index >34 mL/m² 1 point
Tricuspid regurgitation velocity >2.8 m/s 1 point

Clinical Phenotypes

HFpEF encompasses several distinct phenotypes with different underlying pathophysiology:

Hypertensive
Hypertensive HFpEF
Most common phenotype. Long-standing hypertension with concentric LV remodeling, diastolic dysfunction. Often elderly females with obesity.
~60% of HFpEF cases
Metabolic
Metabolic HFpEF
Obesity, diabetes, metabolic syndrome. Systemic inflammation, coronary microvascular dysfunction, insulin resistance.
~30% of HFpEF cases
Fibrotic
Fibrotic/Infiltrative
Cardiac amyloidosis, hypertrophic cardiomyopathy, restrictive cardiomyopathy. Severe diastolic dysfunction.
~10% of HFpEF cases

Differential Diagnosis

  • Non-cardiac dyspnoea: Chronic obstructive pulmonary disease (COPD), pulmonary embolism, anaemia, deconditioning
  • HFrEF with recovered EF: Previous reduced EF that has improved with treatment
  • HFmrEF: Heart failure with mildly reduced ejection fraction (41-49%)
  • Constrictive pericarditis: Similar symptoms but different haemodynamic profile
  • Pulmonary hypertension: Right heart failure with preserved left ventricular function
  • Infiltrative cardiomyopathies: Amyloidosis, sarcoidosis, haemochromatosis
⚠️
Red Flags for Alternative Diagnoses: Severe weight loss, night sweats (malignancy); significant smoking history with productive cough (COPD); acute onset with pleuritic pain (PE); peripheral neuropathy or macroglossia (amyloidosis).

NYHA Functional Classification

Class Symptoms Functional Limitation
Class I No symptoms with ordinary activity No limitation
Class II Mild symptoms with

Clinical Presentation & Diagnostic Criteria

Clinical Presentation

ℹ️
Key Point: HFpEF symptoms are indistinguishable from HFrEF. Diagnosis requires demonstrating preserved LVEF ≥50% with objective evidence of heart failure.

Typical Symptoms

  • Dyspnoea on exertion (most common presenting symptom)
  • Orthopnoea and paroxysmal nocturnal dyspnoea
  • Exercise intolerance and fatigue
  • Lower limb oedema
  • Reduced exercise capacity
  • Chest discomfort or heaviness

Physical Signs

  • Elevated jugular venous pressure (JVP)
  • Third heart sound (S3 gallop) or fourth heart sound (S4)
  • Bilateral basal pulmonary crepitations
  • Peripheral oedema (ankles, legs, sacral)
  • Hepatomegaly and ascites (advanced disease)
  • Displaced or sustained apical impulse

Diagnostic Criteria for HFpEF

⚠️
Diagnostic Challenge: HFpEF diagnosis requires high clinical suspicion as symptoms overlap with many conditions common in elderly patients.

Essential Criteria (All Must Be Present)

1
Clinical Heart Failure
Symptoms and/or signs of heart failure
2
Preserved LVEF
LVEF ≥50% on echocardiography
3
Objective Evidence
Evidence of structural heart disease and/or diastolic dysfunction

HFA-PEFF Diagnostic Algorithm

The Heart Failure Association Pre-test assessment, Echocardiography & natriuretic peptide, Functional testing, and Final aetiology (HFA-PEFF) algorithm provides structured approach:

Step Component Criteria Points
P1 - Pre-test Clinical presentation Typical HF symptoms + signs Major: 2
Minor: 1
Predisposing conditions HTN, AF, DM, obesity, CAD 1 per condition
Elderly Age ≥65 years 1
P2 - Biomarkers NT-proBNP >125 pg/mL (SR) or >365 pg/mL (AF) 1
BNP >35 pg/mL (SR) or >105 pg/mL (AF) 1
E - Echo E/e' septal >15 (2 points) or 9-15 (1 point) 1-2
LAVI >34 mL/m² 1
LVMI ♂ >115 g/m², ♀ >95 g/m² 1
TR velocity >2.8 m/s 1
✅
HFA-PEFF Score Interpretation:
• ≥5 points: High probability of HFpEF
• 2-4 points: Intermediate probability (consider functional testing)
• 0-1 points: Low probability of HFpEF

Differential Diagnosis

Cardiac
Cardiac Causes
• Coronary artery disease
• Hypertensive heart disease
• Valvular heart disease
• Atrial fibrillation
• Restrictive cardiomyopathy
• Constrictive pericarditis
Pulmonary
Respiratory Causes
• COPD/Asthma
• Pulmonary hypertension
• Interstitial lung disease
• Pulmonary embolism
• Sleep-disordered breathing
Other
Non-cardiac Causes
• Chronic kidney disease
• Liver disease
• Venous insufficiency
• Medication-related oedema
• Anaemia
• Thyroid disease

Diagnostic Flowchart

Step 1
Clinical Assessment
Symptoms + signs of heart failure
Risk factors (HTN, DM, obesity, CAD, AF)
Step 2
Natriuretic Peptides
NT-proBNP or BNP
If normal and high clinical suspicion → consider stress testing
Step 3
Echocardiography
LVEF ≥50%
Assess diastolic function, LA size, LV mass
Exclude significant valvular disease
Step 4
Apply HFA-PEFF Score
If ≥5 points: HFpEF diagnosis
If 2-4 points: Consider functional testing
If 0-1 points: Alternative diagnosis
🚨
Red Flags Requiring Urgent Assessment:
• Acute pulmonary oedema
• Severe limiting symptoms at rest
• Signs of cardiogenic shock
• New-onset heart failure with rapid deterioration
• Suspected acute coronary syndrome

Investigations

ℹ️
Diagnostic Approach: HFpEF diagnosis requires clinical syndrome of heart failure with preserved ejection fraction (≥50%) and evidence of structural heart disease, diastolic dysfunction, or elevated natriuretic peptides.

Initial Assessment - Essential Investigations

  • Essential
    12-Lead Electrocardiogram (ECG)
    Assess for arrhythmias, conduction abnormalities, left ventricular hypertrophy, and ischaemic changes. Available in all Australian healthcare facilities.
  • Essential
    Transthoracic Echocardiography (TTE)
    Gold standard for assessing LVEF, diastolic function, valve disease, and structural abnormalities. Available in most Australian hospitals and cardiology clinics. Medicare item 55113.
  • Essential
    Full Blood Count (FBC)
    Screen for anaemia, which is common in HFpEF and affects prognosis. Available universally across Australian pathology services.
  • Essential
    Renal Function (eGFR, Creatinine, Electrolytes)
    Essential for medication dosing and identifying cardiorenal syndrome. Available at all Australian laboratories.
  • Essential
    Liver Function Tests (LFTs)
    Assess for hepatic congestion and guide medication selection. Standard pathology test available nationwide.
  • Essential
    B-type Natriuretic Peptide (BNP) or NT-proBNP
    Critical for diagnosis when clinical uncertainty. NT-proBNP >125 pg/mL supports HF diagnosis. Available in major Australian laboratories. Medicare item 66833.
  • Available
    Chest X-ray
    Assess for pulmonary congestion, cardiomegaly, and exclude respiratory causes. Available in all Australian healthcare facilities.

Specialised Cardiac Investigations

  • Available
    Stress Echocardiography
    Assess diastolic reserve and unmask exercise-induced diastolic dysfunction. Available in major cardiology centres. Medicare item 55123.
  • Referral
    Cardiac MRI
    Gold standard for myocardial characterisation, tissue viability, and infiltrative disease. Limited availability - major hospitals and specialist centres. Medicare item 63464.
  • Specialist
    Invasive Haemodynamic Assessment
    Right heart catheterisation with exercise testing for diagnostic uncertainty. Available in tertiary cardiac centres. Consider if non-invasive testing inconclusive.
  • Available
    Cardiopulmonary Exercise Testing (CPET)
    Assess functional capacity and differentiate cardiac vs respiratory limitation. Available in major Australian cardiac centres.

Investigations for Underlying Aetiology

  • Available
    Thyroid Function Tests
    Screen for hyperthyroidism and hypothyroidism. Standard pathology test available nationwide.
  • Available
    HbA1c and Glucose Studies
    Diabetes is a major risk factor for HFpEF. Essential for risk stratification and management. Available universally.
  • Available
    Lipid Profile
    Assess cardiovascular risk and guide statin therapy. Standard test available at all Australian laboratories.
  • Specialist
    Cardiac Amyloid Screening
    Consider in elderly patients with unexplained HFpEF. Includes serum/urine light chains, SAP scintigraphy, or cardiac biopsy. Available in specialist centres.
  • Referral
    Coronary Angiography
    Consider if ischaemic aetiology suspected or ongoing angina. Available in major hospitals with cardiac catheterisation facilities. Medicare item 38215.
  • Specialist
    Sleep Study
    Sleep apnoea is highly prevalent in HFpEF. Consider referral for polysomnography if clinical suspicion. Available through sleep medicine services.

Monitoring Investigations

Baseline
Complete initial assessment with ECG, echo, blood tests, BNP/NT-proBNP
2-4 weeks
Repeat renal function and electrolytes after medication initiation
3 months
Review BNP/NT-proBNP, renal function, and clinical status
6-12 months
Repeat echocardiography if clinical deterioration or medication changes
Annual
Comprehensive review including echo, blood tests, and functional assessment
⚠️
Diagnostic Challenges: HFpEF diagnosis can be challenging. Consider specialist cardiology referral if diagnostic uncertainty, particularly for invasive haemodynamic assessment or advanced imaging.

Australian Laboratory Availability Summary

Investigation Availability Medicare Item Notes
NT-proBNP/BNP Major labs 66833 24-48 hour turnaround
Troponin Universal 66818 High-sensitivity preferred
Echocardiography Most hospitals 55113 May require referral in rural areas
Cardiac MRI Major centres 63464 Limited rural access
Cardiac catheterisation Tertiary centres 38215 Specialist referral required

Risk Stratification / Severity Scoring

Risk stratification in HFpEF focuses on identifying patients at highest risk of cardiovascular death, heart failure hospitalisation, and functional decline. Unlike HFrEF, prognostic tools for HFpEF are less well-validated, requiring multiparameter assessment.

NYHA I-II
Low Risk
Asymptomatic or mild symptoms with ordinary activity. Preserved functional capacity with minimal impact on daily activities.
Primary care management appropriate
NYHA III
Moderate Risk
Marked limitation of physical activity. Comfortable at rest but symptoms with less than ordinary activity.
Specialist cardiology input required
NYHA IV
High Risk
Unable to carry out physical activity without discomfort. Symptoms at rest or with minimal exertion.
Urgent cardiology referral, consider hospitalisation

H₂FPEF Score

Validated tool to estimate probability of HFpEF diagnosis in patients with unexplained dyspnoea. Score ≥6 suggests high probability of HFpEF.

Variable Criteria Points
H - Heavy (BMI) BMI >30 kg/m² 2
H - Hypertensive ≥2 antihypertensive drugs 1
F - Atrial Fibrillation Paroxysmal or persistent 3
P - Pulmonary hypertension Echo PA systolic pressure >35 mmHg 1
E - Elder Age >60 years 1
F - Filling pressure Echo E/e' >9 1
💡
Interpretation: Score 0-1 = Low probability (15%), Score 2-5 = Intermediate probability (65%), Score 6-9 = High probability (>85%)

MAGGIC Risk Score

Validated for both HFrEF and HFpEF to predict 1-year and 3-year mortality. Particularly useful in Australian populations given diverse comorbidity patterns.

Risk Factor Criteria Points
Age Per year if >70 years 1 per year
Male gender Male 1
BMI Per unit if <30 kg/m² 1 per 5 units below 30
Systolic BP Per 10 mmHg if <120 mmHg 2 per 10 mmHg below 120
Current smoker Active smoking 1
Diabetes mellitus Type 1 or 2 3
COPD Diagnosed COPD 2
HF duration >18 months since diagnosis 2
NYHA Class NYHA III-IV vs I-II 2
Creatinine Per 50 μmol/L if >150 μmol/L 1 per 50 μmol/L above 150

High-Risk Features Requiring Urgent Assessment

🚨
Red Flag Symptoms: Acute severe breathlessness, chest pain, syncope, signs of cardiogenic shock (hypotension, poor perfusion, oliguria)
  • Clinical: NYHA IV symptoms, resting tachycardia >100 bpm, hypotension <90 mmHg systolic, elevated JVP >8 cmH₂O
  • Laboratory: NT-proBNP >2000 ng/L (BNP >500 ng/L), troponin elevation, eGFR <30 mL/min/1.73m²
  • Echocardiographic: Severe diastolic dysfunction (Grade III), severe pulmonary hypertension (PASP >60 mmHg), new wall motion abnormalities
  • Comorbidities: Acute coronary syndrome, severe valvular disease, uncontrolled arrhythmias

Phenotype-Based Risk Stratification

1
Exercise Intolerance Phenotype
Predominant exertional symptoms, preserved resting function. Lower short-term mortality but significant functional impairment.
2
Congestion-Dominant Phenotype
Elevated filling pressures, peripheral oedema, elevated NT-proBNP. Higher hospitalisation risk.
3
Comorbidity-Driven Phenotype
Multiple comorbidities (diabetes, CKD, COPD), systemic inflammation. Highest overall mortality risk.
4
Right Heart Failure Phenotype
Pulmonary hypertension, right ventricular dysfunction, tricuspid regurgitation. Poor prognosis requiring specialist care.

Biomarker Risk Stratification

Biomarker Low Risk Moderate Risk High Risk
NT-proBNP (ng/L) <300 300-1000 >1000
BNP (ng/L) <100 100-300 >300
Troponin I (ng/L) <26 26-40 >40
eGFR (mL/min/1.73m²) >60 30-60 <30

Australian-Specific Risk Factors

⚠️
Geographic Considerations: Remote location increases risk due to delayed access to specialist care, medication supply issues, and limited monitoring capabilities.
  • Aboriginal and Torres Strait Islander peoples: Earlier onset, higher prevalence of diabetes and CKD, increased cardiovascular mortality
  • Rural and remote populations: Delayed diagnosis, limited access to echocardiography and specialist care
  • Culturally diverse populations: Language barriers affecting symptom reporting, cultural concepts of illness
  • Socioeconomic factors: Medication adherence issues, transport barriers to follow-up

Risk-Based Management Pathways

Low Risk
Primary care management: Annual review, lifestyle modification focus, symptom monitoring, 3-6 monthly NT-proBNP if indicated
Moderate Risk
Shared care: Cardiology consultation within 6-8 weeks, 3-monthly reviews, optimization of comorbidities, consider cardiac rehabilitation
High Risk
Specialist management: Urgent cardiology referral (within 2 weeks), consideration for advanced therapies, frequent monitoring, multidisciplinary care
✓
Quality Indicator: Risk stratification should be documented

Acute Management

🚨
Emergency Assessment: Acute HFpEF decompensation requires immediate assessment for precipitating factors and haemodynamic stability. Consider cardiogenic shock, acute coronary syndrome, or hypertensive crisis.

Initial Assessment & Stabilisation

1
Airway & Breathing
Assess for respiratory distress. Apply oxygen if SpO2 <90% or clinical hypoxaemia. Consider NIV if severe pulmonary oedema and no contraindications.
2
Circulation
Monitor BP, heart rate, JVP. Obtain IV access. 12-lead ECG urgently. Assess for signs of cardiogenic shock (SBP <90 mmHg, altered mental state).
3
Precipitant Identification
Assess for AF with RVR, hypertensive crisis, ACS, medication non-compliance, fluid overload, infection, anaemia, or thyrotoxicosis.

Acute Pharmacological Management

Diuretic Therapy - First Line

💧
Furosemide
Lasix® · Loop diuretic · First-line
IV Bolus 40-80 mg IV (start with double usual oral dose)
IV Infusion 5-40 mg/h continuous if inadequate response
Frequency Bolus: 6-12 hourly PRN
Target Urine output >100 mL/h, net negative 1-2L/day
Renal Adj. Higher doses required in CKD (up to 250 mg bolus)
Monitoring Daily weight, U&E, fluid balance
PBS Status ✓ PBS General Benefit
💧
Bumetanide
Alternative loop diuretic
IV Bolus 1-2 mg IV (40:1 ratio to furosemide)
IV Infusion 0.5-4 mg/h continuous
Frequency 6-12 hourly PRN
Advantage Better bioavailability if gut oedema present
Renal Adj. Reduce dose if eGFR <20 mL/min/1.73m²
PBS Status ✓ PBS General Benefit

Vasodilator Therapy

🔄
Glyceryl Trinitrate (GTN)
Anginine® · Nitrate · Preload reduction
Indication SBP >110 mmHg + pulmonary oedema
Initial Dose 10-20 mcg/min IV infusion
Titration Increase by 10-20 mcg/min every 5 minutes
Maximum 200 mcg/min or until SBP drops 10-15%
Monitoring BP every 5 min initially, avoid SBP <90 mmHg
Contraindications Cardiogenic shock, severe AS, recent PDE5 inhibitor
PBS Status ✓ PBS General Benefit
🔄
Isosorbide Dinitrate
ISDN · Alternative nitrate
Initial Dose 1-2 mg/h IV infusion
Titration Increase by 1-2 mg/h every 10-15 minutes
Maximum 10-20 mg/h
Advantage Longer half-life than GTN
PBS Status ✓ PBS General Benefit
⚠️
HFpEF Vasodilator Caution: Patients with HFpEF are preload-dependent. Use nitrates cautiously and avoid excessive preload reduction which may compromise cardiac output.

Rate Control (Atrial Fibrillation)

💓
Metoprolol
Betaloc® · Selective β1-blocker
IV Bolus 2.5-5 mg IV over 2-5 minutes
Repeat Every 5 minutes to max 15 mg
Target HR 60-100 bpm (avoid <60 bpm in HFpEF)
Contraindications Cardiogenic shock, severe HF decompensation
PBS Status ✓ PBS General Benefit
💓
Diltiazem
Cardizem® · Non-DHP CCB · Alternative
IV Bolus 0.25 mg/kg (max 20 mg) over 2 minutes
Second Dose 0.35 mg/kg after 15 min if needed
IV Infusion 5-15 mg/h (if bolus effective)
Advantage Preferred if β-blocker contraindicated
PBS Status ✓ PBS General Benefit

Inotropic Support (Cardiogenic Shock)

🚨
Inotrope Use in HFpEF: Use only in cardiogenic shock with SBP <90 mmHg or signs of hypoperfusion. Avoid in pure diastolic dysfunction as may worsen relaxation.
⚡
Dobutamine
Inotropic agent · First choice in HFpEF
Starting Dose 2.5-5 mcg/kg/min IV infusion

Long-term Management

Comprehensive Management Framework

Long-term management of HFpEF requires a multifaceted approach addressing underlying comorbidities, symptom management, and prevention of disease progression. Evidence-based therapies focus on managing associated conditions rather than directly targeting heart failure itself.

ℹ️
Key Principle: Unlike HFrEF, no medications have consistently demonstrated mortality benefit in HFpEF. Management centres on treating comorbidities and symptom relief.

Evidence-Based Pharmacological Therapy

SGLT2 Inhibitors - First-Line Therapy

💊
Dapagliflozin
Forxiga® · SGLT2 inhibitor · First-line
Adult Dose 10 mg once daily
Route Oral
Duration Ongoing
Renal Adj. eGFR ≥25 mL/min/1.73m² required
Hepatic Adj. No adjustment required
PBS Status ✓ PBS General Benefit (HF indication)
✅
DELIVER-HF Evidence: Dapagliflozin reduced cardiovascular death and worsening heart failure events by 18% in patients with HFpEF (EF ≥40%).

Diuretics for Volume Management

💧
Furosemide
Lasix® · Loop diuretic · First-line
Adult Dose 20-80 mg daily (titrate to response)
Route Oral (IV if severe congestion)
Duration Ongoing (adjust based on symptoms)
Renal Adj. Higher doses may be required
Hepatic Adj. Caution in hepatic impairment
PBS Status ✓ PBS General Benefit

Blood Pressure Management

🩸
Candesartan
Atacand® · ARB · Preferred for HFpEF
Adult Dose 4-32 mg once daily
Route Oral
Duration Ongoing
Renal Adj. Start low dose if CrCl <60 mL/min
Hepatic Adj. Reduce dose in hepatic impairment
PBS Status ✓ PBS General Benefit
🩸
Amlodipine
Norvasc® · Calcium channel blocker
Adult Dose 2.5-10 mg once daily
Route Oral
Duration Ongoing
Renal Adj. No adjustment required
Hepatic Adj. Reduce dose in hepatic impairment
PBS Status ✓ PBS General Benefit
⚠️
Beta-blockers: Use cautiously in HFpEF. May impair diastolic filling and exercise capacity. Consider only for specific indications (AF, CAD, hypertension).

Comorbidity Management

Diabetes Management

  • Target HbA1c: <7.0% (individualise based on patient factors)
  • Prefer SGLT2 inhibitors or GLP-1 agonists
  • Avoid thiazolidinediones (fluid retention risk)
  • Regular diabetes educator review

Obesity Management

  • Target BMI: <30 kg/m² (or <27 if comorbidities)
  • Structured weight loss programs
  • Dietitian referral for all patients
  • Consider bariatric surgery if BMI >40

Atrial Fibrillation Management

⚡
Apixaban
Eliquis® · DOAC · First-line anticoagulation
Adult Dose 5 mg twice daily (2.5 mg if dose reduction criteria met)
Route Oral
Duration Ongoing if CHA₂DS₂-VASc ≥2
Renal Adj. Reduce dose if CrCl 15-50 mL/min + 2 other criteria
Hepatic Adj. Contraindicated in severe hepatic impairment
PBS Status ✓ PBS General Benefit

Non-Pharmacological Management

1
Exercise Training
Structured aerobic exercise 3-4 times weekly, 30-45 minutes. Cardiac rehabilitation referral strongly recommended.
2
Dietary Modification
Sodium restriction <2g daily, DASH diet pattern. Dietitian consultation for personalised plan.
3
Weight Management
Target 5-10% weight loss if overweight. Regular monitoring and support programs.
4
Sleep Apnoea Screening
Screen all patients (Epworth Sleepiness Scale). CPAP therapy if OSA confirmed improves outcomes.

Monitoring and Follow-up Schedule

2-4 weeks
Initial follow-up: Assess symptoms, BP, heart rate, weight, renal function, electrolytes. Medication tolerance and adherence.
3 months
Stability assessment: Functional capacity (6MWT if available), NYHA class, quality of life questionnaire. Echocardiogram if clinically indicated.
6 months

Device Therapy

ℹ️
Key Concept: Device therapy in HFpEF is more limited compared to HFrEF, with fewer evidence-based options. Current focus is on atrial fibrillation management, pacemaker therapy for specific indications, and investigational devices.

Pacemaker Therapy

Indications for Pacemaker Implantation

Class I
Strong Indications
Symptomatic bradycardia with heart block or sinus node dysfunction causing symptoms attributable to bradycardia
Consider DDDR pacing to maintain AV synchrony
Class IIa
Reasonable Indications
Chronotropic incompetence contributing to exercise limitation in HFpEF patients
Rate-responsive pacing may improve exercise capacity
Class IIb
Consider
Asymptomatic bradycardia with ventricular pauses >3 seconds during waking hours
Individual risk-benefit assessment required
⚠️
Important: In HFpEF, maintaining AV synchrony is crucial due to the increased reliance on atrial contribution to ventricular filling. Avoid unnecessary RV pacing.

Pacing Considerations in HFpEF

  • AV Sequential Pacing: Preferred when possible to maintain optimal ventricular filling
  • Rate Response: Important for chronotropic incompetence common in HFpEF
  • His Bundle Pacing: Consider when available to maintain physiological conduction
  • Avoid Unnecessary RV Pacing: Can worsen diastolic dysfunction

Cardiac Resynchronization Therapy (CRT)

🚫
Not Recommended: CRT is not indicated in HFpEF patients with normal QRS duration (<130 ms) and LVEF ≥50%. Limited evidence for benefit in this population.

Potential CRT Considerations

May Consider CRT if:
  • QRS ≥130 ms with LBBB morphology
  • Significant RV pacing requirement (>40%)
  • Symptomatic despite optimal medical therapy
  • Evidence of mechanical dyssynchrony
Assessment Required:
  • Comprehensive echocardiography
  • 6-minute walk test
  • Quality of life assessment
  • Cardiothoracic surgery consultation

Implantable Cardioverter Defibrillator (ICD)

⚠️
Limited Evidence: ICD therapy for primary prevention in HFpEF has limited evidence. Risk stratification for sudden cardiac death is more complex than in HFrEF.

ICD Considerations in HFpEF

1
Risk Assessment
Evaluate for high-risk features: significant arrhythmias, syncope, family history of SCD, infiltrative cardiomyopathy
2
Secondary Prevention
ICD indicated for survivors of VF/VT if good functional status and meaningful survival expected >1 year
3
Primary Prevention
Consider in selected high-risk patients with non-ischaemic cardiomyopathy and specific risk factors
4
Shared Decision Making
Discuss limited evidence, competing risks, and patient values/preferences

Atrial Fibrillation Management Devices

Left Atrial Appendage Occlusion (LAAO)

🔧
WATCHMAN Device
Boston Scientific · LAA Occlusion
Indication AF with contraindication to anticoagulation
CHA₂DS₂-VASc ≥2 (men) or ≥3 (women)
Contraindications Thrombus in LAA, bleeding within 30 days
Success Rate 95-98% procedural success
Follow-up TOE at 45 days and 6 months
Medicare ✓ Medicare Coverage
ℹ️
LAAO in HFpEF: Particularly relevant as HFpEF patients often have high bleeding risk due to age, comorbidities, and polypharmacy. LAAO may be preferred over long-term anticoagulation in selected patients.

Pulmonary Vein Isolation (PVI) / Catheter Ablation

Class I
Recommended
Symptomatic AF refractory to antiarrhythmic drugs
Paroxysmal or early persistent AF
Class IIa
Reasonable
First-line therapy for symptomatic paroxysmal AF in selected patients
Young patients, athlete's heart, preference for rhythm control

Novel and Investigational Devices

Interatrial Shunt Devices

⚠️
Investigational: Interatrial shunt devices (REDUCE LAP-HF II trial) showed mixed results. Not currently approved for routine clinical use in Australia.
Concept:
  • Creates controlled left-to-right atrial shunt
  • Reduces left atrial pressure during exercise
  • Aims to improve exercise tolerance
  • Percutaneous implantation via transseptal approach
Current Status:
  • REDUCE LAP-HF II trial results mixed
  • Not approved by TGA
  • Available only in research settings
  • Further trials ongoing

Cardiac Contractility Modulation (CCM)

ℹ️
Limited Evidence: CCM devices deliver non-excitatory electrical signals during the refractory period. Limited data in HFpEF population. Not routinely recommended.

Device Selection Algorithm

Initial Assessment
Evaluate: Rhythm disorders, conduction abnormalities, symptoms, functional status, comorbidities, life expectancy
Bradycardia
Consider pacemaker: Symptomatic bradycardia, chronotropic incompetence, high-degree AV block
Atrial Fibrillation
Rhythm vs Rate: Consider catheter ablation for symptomatic AF, LAAO for anticoagulation contraindication
High-Risk Features
ICD consideration: Secondary prevention, selected primary prevention cases with MDT discussion
Ongoing Monitoring
Device clinic: Remote monitoring, lead surveillance, battery status, symptom correlation

Pre-implant Assessment

  • Essential
    12-lead ECG
    Rhythm analysis, QRS duration, AV conduction assessment
  • Essential
    Transthoracic Echocardiography
    LVEF, diastolic function, valvular disease, RV function
  • Available
    24-hour Holter Monitor
    Arrhythmia

    Special Populations

    🤰 Pregnancy
    ACE Inhibitors Contraindicated - teratogenic. Discontinue immediately if pregnancy confirmed.
    ARBs Contraindicated - teratogenic effects similar to ACE inhibitors.
    Spironolactone Generally avoided - limited safety data, potential anti-androgenic effects.
    Beta-blockers Metoprolol preferred if required. Monitor for IUGR and neonatal hypoglycemia.
    Diuretics Use cautiously - may reduce placental perfusion. Furosemide preferred if needed.
    HFpEF in pregnancy requires specialist cardio-obstetric management. Consider peripartum cardiomyopathy differential.
    👶 Paediatrics
    HFpEF is rare in children. Most paediatric heart failure is HFrEF from congenital heart disease or cardiomyopathy.
    ACE Inhibitors Enalapril 0.1-0.5 mg/kg/day divided BD. Start low, titrate carefully with BP monitoring.
    Beta-blockers Metoprolol 1-2 mg/kg/day divided BD-TDS. Limited evidence in paediatric HFpEF.
    Diuretics Furosemide 1-2 mg/kg/day. Monitor electrolytes and renal function closely.
    Paediatric cardiology consultation essential. Consider underlying causes including infiltrative diseases.
    👴 Elderly (≥75 years)
    Majority of HFpEF patients are elderly. Age-related physiological changes increase complexity of management.
    ACE Inhibitors/ARBs Start at 50% usual dose. Higher risk of hypotension, AKI, hyperkalemia. Monitor closely.
    Beta-blockers Start very low dose. Risk of bradycardia, heart block. May worsen cognitive function.
    Diuretics Lower threshold for dehydration, electrolyte disturbance. Monitor renal function weekly initially.
    Polypharmacy Review all medications regularly. Drug interactions common. Deprescribing when appropriate.
    Consider frailty assessment, falls risk, cognitive impairment. Shared decision-making regarding treatment goals.
    🫘 Renal Impairment
    CKD is common in HFpEF patients. Cardiorenal syndrome complicates management significantly.
    eGFR 30-60 mL/min/1.73m² Standard doses usually appropriate. Monitor eGFR and K+ weekly initially, then monthly.
    eGFR 15-30 mL/min/1.73m² Reduce ACE inhibitor/ARB dose by 50%. Consider nephrology consultation.
    eGFR <15 mL/min/1.73m² Avoid ACE inhibitors/ARBs unless on dialysis. Nephrology co-management essential.
    Diuretics May require higher doses. Loop diuretics preferred. Monitor for worsening kidney function.
    SGLT2 inhibitors Can be used if eGFR ≥20 mL/min/1.73m². May slow CKD progression.
    🫀 Hepatic Impairment
    Hepatic congestion common in HFpEF. Drug metabolism may be impaired in severe liver dysfunction.
    Child-Pugh A Standard dosing usually appropriate. Monitor liver function tests regularly.
    Child-Pugh B Reduce doses of hepatically metabolized drugs by 50%. Avoid spironolactone.
    Child-Pugh C Avoid hepatically metabolized drugs. Use renally eliminated alternatives where possible.
    Beta-blockers Atenolol preferred (renal elimination). Avoid propranolol, carvedilol in severe impairment.
    Diuretics Monitor for hepatorenal syndrome. Avoid potassium-sparing diuretics in severe impairment.
    🛡️ Immunocompromised
    Immunosuppression may mask signs of infection. Consider drug interactions with immunosuppressive agents.
    ACE Inhibitors May increase risk of angioedema in patients on mTOR inhibitors (sirolimus, everolimus).
    Infection Screening Exclude active infection before heart failure treatment. Monitor for opportunistic infections.
    Drug Interactions Check interactions with calcineurin inhibitors, antimetabolites, biological agents.
    Vaccination Ensure influenza, pneumococcal, COVID-19 vaccines current (inactivated vaccines only).
    Coordinate care with transplant/immunology teams. Consider cardiotoxic effects of chemotherapy or radiation.
    ℹ️
    Clinical Pearl: Elderly patients with HFpEF often have multiple comorbidities requiring careful medication reconciliation and consideration of drug interactions. Start low, go slow, and monitor closely.
    Dose Adjustment Principles
    • Start at lowest effective dose in elderly and those with organ dysfunction
    • Titrate slowly with frequent monitoring of vital signs, renal function, and electrolytes
    • Consider drug interactions, especially in polypharmacy situations
    • Regular medication review and deprescribing when appropriate
    • Shared decision-making regarding treatment goals and quality of life
    Monitoring Parameters by Population
    • Elderly: Weekly BP, daily weights, monthly U&E, functional assessment
    • Renal impairment: eGFR and K+ at baseline, 1-2 weeks, then monthly
    • Hepatic impairment: LFTs, albumin, INR, signs of hepatic encephalopathy
    • Pregnancy: Specialist cardio-obstetric monitoring, fetal surveillance
    • Paediatric: Growth parameters, developmental assessment, specialist follow-up

    Cardiac Rehabilitation

    Evidence Base for HFpEF

    Cardiac rehabilitation (CR) is a Class I recommendation for all heart failure patients, including HFpEF, based on strong evidence demonstrating improvements in exercise capacity, quality of life, and reduced hospitalizations. The REHAB-HF trial specifically demonstrated benefits in older adults with heart failure regardless of ejection fraction.

    ✅
    Evidence-Based Benefits: Cardiac rehabilitation improves 6-minute walk distance by 20-40m, reduces heart failure hospitalizations by 13%, and improves Minnesota Living with Heart Failure Questionnaire scores by 5-8 points in HFpEF patients.

    Core Components of HFpEF Cardiac Rehabilitation

    1
    Exercise Assessment
    Comprehensive evaluation including symptom-limited exercise stress test, 6-minute walk test, and assessment of exercise limitations specific to HFpEF (diastolic dysfunction, chronotropic incompetence).
    2
    Individualised Exercise Prescription
    Combination of aerobic and resistance training tailored to HFpEF pathophysiology. Focus on improving diastolic filling, peripheral muscle function, and chronotropic response.
    3
    Education & Self-Management
    Disease-specific education about HFpEF, symptom monitoring, medication adherence, and lifestyle modifications including weight management and dietary sodium restriction.
    4
    Psychosocial Support
    Assessment and management of depression, anxiety, and social isolation common in HFpEF patients. Include family/caregiver education and support.

    Exercise Prescription for HFpEF

    Aerobic Exercise

    • Frequency: 3-5 days per week
    • Intensity: 40-70% HRR or RPE 11-14
    • Duration: 20-60 minutes (can be interval training)
    • Modalities: Walking, cycling, swimming, or arm ergometry
    • Progression: Gradual increase over 8-12 weeks

    Resistance Training

    • Frequency: 2-3 days per week
    • Intensity: 40-70% 1RM or RPE 11-13
    • Sets/Reps: 1-3 sets of 8-15 repetitions
    • Exercises: 8-10 major muscle groups
    • Rest: 48-72 hours between sessions
    ⚠️
    HFpEF-Specific Considerations: Start at lower intensities due to impaired chronotropic response. Monitor for excessive blood pressure response during exercise. Consider interval training to improve diastolic filling time.

    Australian Cardiac Rehabilitation Programs

    Program Type Setting Duration Availability Medicare Benefits
    Phase II Supervised Hospital/Community Centre 6-12 weeks All major centres Yes (Item 10953-10962)
    Home-Based Programs Home with telehealth support 8-12 weeks Limited centres Yes (Item 10953-10962)
    Community Programs Local health services Ongoing Variable by location Limited coverage
    Heart Foundation Programs Community centres Ongoing Most regions No

    Special Considerations for HFpEF Populations

    👴 Elderly Patients
    Exercise Intensity Start at 30-40% HRR due to multiple comorbidities and deconditioning
    Balance Training Include falls prevention exercises and balance training components
    Cognitive Assessment Screen for cognitive impairment that may affect program participation
    Frailty Screening Use validated frailty tools to tailor exercise prescription
    🫘 Comorbid Conditions
    Diabetes Monitor blood glucose, coordinate with endocrinologist, include diabetes education
    CKD Monitor fluid status, adjust exercise intensity based on eGFR and symptoms
    COPD Pulmonary rehabilitation integration, monitor oxygen saturation during exercise
    Atrial Fibrillation Use RPE rather than heart rate targets, monitor for symptoms during exercise

    Monitoring and Outcome Measures

    Baseline
    • 6-minute walk test
    • Symptom-limited exercise stress test
    • Kansas City Cardiomyopathy Questionnaire
    • Minnesota Living with Heart Failure Questionnaire
    • Depression screening (PHQ-9)
    4-6 weeks
    • Progress assessment and exercise prescription modification
    • Symptom evaluation and medication review
    • Adherence counselling and barrier identification
    12 weeks
    • Repeat 6-minute walk test
    • Quality of life questionnaires
    • Transition to long-term maintenance program
    • GP communication and ongoing care plan
    6 months
    • Long-term outcome assessment
    • Hospitalization review
    • Maintenance program participation assessment

    Barriers and Solutions in Australia

    Geographic Access
    Limited CR programs in rural/remote areas. Solutions: Telehealth delivery, mobile cardiac rehabilitation units, partnership with local health services.
    Patient Referral
    Low referral rates for HFpEF patients. Solutions: Automatic referral systems, GP education, specialist cardiologist engagement.
    Program Capacity
    Waiting lists for programs. Solutions: Home-based alternatives, community program partnerships, extended program duration options.
    Cultural Barriers
    Language and cultural barriers for CALD populations. Solutions: Interpreter services, culturally appropriate program modifications, community health worker involvement.
    ℹ️
    Medicare Benefits: Medicare provides rebates for up to 10 cardiac rehabilitation sessions per calendar year (Items 10953-10962). Chronic Disease Management Plans may provide additional allied health sessions for exercise physiology.

    Long-Term Maintenance and Community Programs

    Successful cardiac rehabilitation requires transition to long-term maintenance programs. Australian options include:

    • Heart Foundation Walking Groups: Free community-based programs available in most areas
    • Community Fitness Centres: Subsidised access through some health insurance providers
    • Exercise Right Programs: Exercise & Sports Science Australia clinician-referred programs
    • Telehealth Maintenance: Remote monitoring and coaching programs
    • Primary Care Integration: GP and practice nurse-led maintenance programs
    ✅
    Key Message: Cardiac rehabilitation is essential for all HFpEF patients and should be considered a standard component of care. Early referral, individualised programming, and long-term maintenance are crucial for optimal outcomes.

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    • 02
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    • 03
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