HFpEF Expert Panel Report

Parikh KS, Sharma K, Fiuzat M, et al.
Heart Failure With Preserved Ejection Fraction Expert Panel Report: Current Controversies and Implications for Clinical Trials. JACC Heart Fail 2018;6:619-632.

The following are summary points to remember from this expert panel report on heart failure with preserved ejection fraction (HFpEF):

  1. The authors discuss relative merits of whether HFpEF should be classified as a single clinical entity or whether to view it as a condition that is comprised of many different diseases. Challenges associated with HFpEF begin with its definition. HFpEF is usually diagnosed after excluding noncardiac causes of shortness of breath that can mimic HF, and alternate established diseases with left ventricular EF (LVEF) >50% causing HF symptoms (e.g., constrictive pericarditis, infiltrative cardiomyopathies, isolated right-sided HF, valvular heart disease, non–group 2 pulmonary hypertension [PH]). There is controversy about whether HFpEF patients respond similarly to interventions. How HFpEF should be categorized has overarching implications for future treatment goals and approaches to drug development, and both perspectives are discussed.
  2. The authors discuss relative merits of whether HFpEF should be classified clinically or should be based on mechanistic pathways. The authors believe that whatever scheme is developed should be flexible (i.e., have the capacity to adapt to new findings) and practical (i.e., can be classified in a variety of settings), with the goal of driving specific therapies in distinct subgroups.
  3. The authors discuss relative merits of whether clinical trials evaluating HFpEF should include a broad or narrower group of subjects and focused on individual subpopulations such as those with metabolic disorders, pulmonary vascular disease, or elevated left atrial pressure.
  4. The authors discuss relative merits of whether HFpEF trials should use quality-of-life (QOL) metrics as main endpoints. Changes in QOL and functional capacity in patients living with chronic diseases are often overlooked or underemphasized as important endpoints. For example, exercise-limited and primarily shortness of breath HFpEF patients may not decompensate in a way that would require hospitalization, but they may benefit from an increase in walking distance and functional capacity. Other patients may have more difficulty with volume status/redistribution and benefit from interventions to prevent or address volume overload and frequent hospitalizations. To refine endpoints and increase the relevancy of findings, the authors of this paper believe it is necessary to develop more sophisticated clinical phenotyping and target testing of interventions to the goals of patients in subphenotypes.
  5. The authors of this study opined that design of meaningful research on HFpEF patients should involve the full scope of stakeholders, including investigators, regulators, industry, and payers, and must consider the lessons learned thus far to understand how future trials and observational studies will close critical knowledge gaps and lead to optimal care for the patient with HFpEF.

Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Pericardial Disease, Pulmonary Hypertension and Venous Thromboembolism, Valvular Heart Disease, Acute Heart Failure, Chronic Heart Failure, Pulmonary Hypertension

Keywords: Atrial Pressure, Cardiomyopathies, Chronic Disease, Dyspnea, Heart Failure, Heart Failure, Diastolic, Heart Valve Diseases, Hypertension, Pulmonary, Geriatrics, Metabolic Diseases, Pericarditis, Constrictive, Quality of Life, Stroke Volume, Vascular Diseases

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