Heart Failure with Preserved Ejection Fraction (HFpEF)- Short Questions-FAQs

1. What defines HFpEF?
Heart failure symptoms with LVEF ≥50% and objective evidence of elevated LV filling pressures.

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2. Why is HFpEF not synonymous with diastolic dysfunction?
HFpEF is a systemic inflammatory cardiometabolic syndrome involving heart, vessels, lungs, kidneys, and skeletal muscle.

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3. What proportion of total HF does HFpEF constitute?
Approximately 50% and increasing worldwide.

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4. Which population is most affected by HFpEF?
Elderly patients, women, and individuals with obesity and hypertension.

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5. Central molecular pathway in HFpEF?
↓ NO–cGMP–PKG signaling due to coronary microvascular inflammation.

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6. Role of systemic inflammation in HFpEF?
It promotes endothelial dysfunction, myocardial fibrosis, and increased LV stiffness.

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7. Why is obesity pivotal in HFpEF?
It drives inflammation, increases plasma volume, worsens diastolic reserve, and suppresses BNP.

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8. Can normal BNP exclude HFpEF?
No. BNP may be normal, especially in obese HFpEF patients.

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9. Why are natriuretic peptides lower in HFpEF than HFrEF?
Smaller LV cavity size and obesity-related suppression.

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10. Most common presenting symptom?
Exertional dyspnea.

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11. Why is exercise intolerance disproportionate in HFpEF?
Due to chronotropic incompetence, impaired LV filling reserve, and peripheral oxygen extraction defects.

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12. Key echocardiographic marker of raised filling pressure?
Elevated E/e′ ratio.

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13. Role of LA enlargement in HFpEF?
Reflects chronic elevation of LV filling pressures.

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14. What does TR velocity signify?
Pulmonary hypertension secondary to elevated left-sided pressures.

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15. What is the H₂FPEF score used for?
Estimating probability of HFpEF in dyspneic patients.

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16. Which H₂FPEF component carries maximum weight?
Atrial fibrillation.

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17. HFA-PEFF score ≥5 indicates?
Definite HFpEF.

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18. Best test when diagnosis is uncertain?
Invasive exercise hemodynamic testing.

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19. Diagnostic exercise PAWP cutoff?
≥25 mmHg.

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20. Typical pulmonary hypertension pattern in HFpEF?
Post-capillary ± pre-capillary pulmonary hypertension.

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21. Prognostic impact of RV dysfunction?
Strong predictor of mortality and hospitalization.

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22. Why are beta-blockers controversial in HFpEF?
They may worsen chronotropic incompetence and exercise capacity.

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23. Role of diuretics in HFpEF?
Symptomatic relief only; no disease modification.

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24. Which drug class has consistent outcome benefit?
SGLT2 inhibitors.

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25. Key trials supporting SGLT2 inhibitors?
EMPEROR-Preserved and DELIVER.

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26. Is SGLT2 benefit dependent on diabetes?
No. Benefit is independent of diabetes status.

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27. Role of RAAS inhibitors in HFpEF?
Mainly for comorbidity control; limited outcome benefit.

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28. Which subgroup showed ARNI benefit in PARAGON-HF?
EF 45–57%.

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29. TOPCAT primary benefit?
Reduction in HF hospitalizations.

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30. Why did TOPCAT results vary regionally?
Differences in adherence and patient selection.

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31. Importance of AF control in HFpEF?
AF worsens filling pressures and symptoms.

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32. Preferred AF strategy in HFpEF?
Rhythm control when feasible.

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33. Effect of weight loss in HFpEF?
Significant improvement in symptoms and hemodynamics.

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34. Role of sleep apnea treatment?
Reduces sympathetic drive and HF burden.

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35. Iron deficiency relevance?
Common and associated with reduced exercise capacity.

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36. Are nitrates useful in HFpEF?
No; they reduce activity levels (NEAT-HFpEF).

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37. Why is arterial stiffness important?
It worsens LV–arterial coupling and diastolic reserve.

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38. HFpEF vs HFrEF mortality?
Overall mortality is similar.

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39. Most common cause of hospitalization?
Congestion.

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40. Can EF alone predict HFpEF severity?
No. EF is poorly correlated with symptoms.

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41. Why is HFpEF considered heterogeneous?
Multiple phenotypes driven by different comorbidities.

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42. Importance of phenotype-based therapy?
Improves symptom control and outcomes.

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43. Renal dysfunction impact?
Worsens volume control and prognosis.

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44. Role of exercise training?
Improves peak VO₂ and quality of life.

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45. Why resting echo may be normal?
HFpEF abnormalities often manifest only during exercise.

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46. HFpEF and microvascular dysfunction?
Central mechanism causing myocardial stiffness.

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47. Is digoxin useful in HFpEF?
No proven benefit except rate control in AF.

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48. Why comorbidity management is crucial?
Comorbidities drive inflammation and outcomes.

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49. Key prognostic markers?
Pulmonary hypertension, RV dysfunction, comorbidity burden.

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50. One-line essence of HFpEF?
HFpEF is a systemic inflammatory cardiometabolic disease with preserved EF but impaired reserve.