Treatment options for

Heart Failure with Preserved Ejection Fraction

Heart failure is a common complex clinical syndrome of symptoms and signs caused by impairment of the heart’s action as a pump supporting the circulation.

Heart Failure with Preserved Ejection Fraction (HF-PEF), previously known as “diastolic” heart failure, is characterised by normal left ventricular systolic function despite symptoms and signs of heart failure.

  • It is poorly understood compared to Heart Failure with Reduced Ejection Fraction (HF-REF), more challenging to diagnose and has more limited treatment options available.

There is no single diagnostic test. Use clinical judgement based on history, physical examination and investigations.

Diagnosis may be confirmed by a combination of:

  • symptoms or signs of heart failure
  • raised serum NT-proBNP >400ng/l
  • echocardiography
    • In HF-PEF, standard echocardiography may appear normal. Specialist imaging may be needed to demonstrate left ventricular diastolic dysfunction.
  • specialist assessment (recommended) to confirm the diagnosis

HF-PEF accounts for roughly half of all cases of heart failure. It is more common in older patients, women and those with multiple co-morbidities.

The diagnosis is easy to miss. Chronic symptoms such as fatigue and reduced exercise tolerance may not be readily attributed to heart failure,  especially in the context of multi-morbidities and/or a normal echocardiogram.

"Normal" left ventricular function and classification of symptoms

Definition of preserved left ventricular ejection fraction (LVEF)

There is not worldwide consensus on this, but a LVEF >40% is generally thought to represent preserved ejection fraction.

  • NICE uses this 40% threshold to define heart failure with reduced ejection fraction (HF-REF), i.e., where the LVEF is <40%1
  • the 40-49% LVEF range is a slightly borderline area, with other classifications including this within HF-REF
    • cardiologists may vary their use of these thresholds on an individual basis

Heart failure (of all types) may be classified by symptoms

New York Heart Association (NYHA) Functional Classification3:

Class Description
I No limitation of physical activity Ordinary physical activity does not cause undue fatigue, palpitation, shortness of breath
II Slight limitation of physical activity Ordinary physical activity results in fatigue, palpitation, shortness of breath
III Marked limitation of physical activity Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or shortness of breath
IV Unable to carry on any physical activity without discomfort Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases



1)National Institute for Health and Care Excellence. Chronic Heart Failure in Adults: diagnosis and management [Internet]. [London]: NICE; 2018 (NICE guideline [NG181])

2)Ponikowski P, Voors AA, Anker SD et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016; 37(27): 2129–2200

3)Dolgin M, Association NYH, Fox AC, Gorlin R, Levin RI, New York Heart Association. Criteria Committee. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. 9th ed. Boston, MA: Lippincott Williams and Wilkins; March 1, 1994

Understanding prognosis

Untreated, heart failure is progressive and carries a poor prognosis:

  • before modern treatments, 5-year survival rates were 30-40%
  • prognosis is complex, and depends on age, setting, sex and other factors

These selected figures are a guide, though there is significant uncertainty:

  • survival rates in the context of standard care at the time
  • they combine data on both HF-REF (reduced) and HF-PEF (preserved) ejection fraction

Overall survival rates

Survival rates at: 1 year 5 years 10 years 15 years
81% 48% 26% 13%

Year of initial diagnosis*

2016 2012 2007 2000

* Defined by first recorded clinical code

Source: UK Primary Care database study 20192

Survival rates by age at diagnosis


  • HF-PEF and HF-REF combined
Survival rates at: 1 year 5 years 10 years 15 years
Age: 45-54 years 90% 79% 65% 54%
55-64 88% 71% 52% 38%%
65-74 84% 59% 35% 17%
75-84 77% 43% 18% 6%
85-94 63% 22% 4% 0.2%
≥95 44% 6%

Source: UK Primary Care database study 20192

Survival rates for HF-REF v HF-PEF v LVSD without HF


  • HF-REF carries a worse prognosis than HF-PEF
Survival rate at: 5 years 10 years
HF-REF 53% 27%
HF-PEF 62% 26%
LVSD* ≤40% but no HF 69% 38%

* LVSD, left ventricular systolic dysfunction

Source: UK Primary Care cohort study 20143

  • patients identified from UK primary care lists and pro-actively screened to assess for heart failure and asymptomatic LVSD
  • diagnosed between: 1995 and 1999, followed up until 2009

Similar differences are seen in studies around the world over time:

Survival rate at: 5 years
HF-REF 63%
HF-PEF 70%

Source: Systematic review 2019(pools data from studies 1987-2017)

Survival rates by NT-proBNP level


  • HF-PEF and HF-REF combined
Survival rate at: 1 year 5 years 10 years
NT-proBNP*:         <400 79% 54% 30%
400-1999 81% 50% 24%
≥2000 73% 38% 18%

* NT-proBNP measured at time of diagnosis, pg/ml.

Source: UK Primary Care database study 20204

Survival rates by diagnosis at hospital admission v community


  • HF-PEF and HF-REF combined

Survival rates are worse for those first diagnosed during acute hospital admission:

Survival rate at: 1 year 5 years 10 years 15 years
Diagnosed in community 81% 52% 29% 15%
Diagnosed at hospital admission 69% 37% 18% 8%

Source: UK Primary Care database study 20192

Survival rates men v women


  • Age adjusted mortality rates are roughly the same for men and women.
  • However, women are diagnosed on average 5 years older than men, so have higher crude mortality rates5.



1)Jones NR, Roalfe AK, Adoki I et al. Survival of patients with chronic heart failure in the community: a systematic review and meta-analysis. Eur J Heart Fail 2019; 21: 1306-1325

2)Taylor CJ, Ordóñez-Mena JM, Roalfe AK et al. Trends in survival after a diagnosis of heart failure in the United Kingdom 2000-2017: population based cohort study.

3)Taylor CJ, Roalfe AK, Iles R, Hobbs FR. Ten-year prognosis of heart failure in the community: follow-up data from the Echocardiographic Heart of England Screening (ECHOES) study. Eur J Heart Fail 2012; 14: 176-184

4)Taylor CJ, Lay-Flurrie SL, Ordóñez-Mena JM et al. Natriuretic peptide level at heart failure diagnosis and risk of hospitalisation and death in England 2004–2018

5)Taylor CJ, Ordóñez-Mena JM, Jones NR et al. National trends in heart failure mortality in men and women, United Kingdom, 2000–2017. Eur J Heart Fail 2021; 23: 3-12

Treatment options:

Treatment strategies


Loop diuretics reduce symptoms and signs of fluid overload.

Many patients may need to remain on a maintenance dose, though these do not need to be continued once fluid overload has resolved and if it does not recur.

Managing co-morbidities

Optimising the management of general cardiovascular risk factors is advised, as this improves prognosis overall, though there is no evidence of a direct effect on the progression of HF-PEF itself.

Optimising management of other co-morbidities such respiratory disease or angina may improve general symptoms such as breathlessness and exercise tolerance.

Long-term therapies

Unfortunately, there is no evidence that the range of treatments available for HF-REF (such as ACE inhibitors and beta-blockers) improve prognosis for those with HF-PEF.

SGLT2 inhibitors

There is emerging evidence of benefit of SGLT2 inhibitors in HF-PEF, though this has not yet been appraised by NICE.