The Management of Heart Failure with Preserved Ejection Fraction (HFpEF)

Heart failure is a clinical syndrome. Given that as many patients have a preserved ejection fraction as they do a reduced one, we have dramatically underrepresented HFpEF patients in trials. We have only performed 4 trials in HFpEF specifically, and two trials that recruited both HFpEF and HFrEF. When we consider the similarity in outcomes and neurohormonal activation between HFrEF and HFpEF, the huge amount of consistent trial data that we have for the benefits of ACE inhibitors, ARBs, beta- blockers and aldosterone antagonists in HFrEF, and the much more limited number of trials of similar agents showing near statistically significant benefits in HFpEF (even though none of the trials is absolutely definitive) the time has come to use Bayesian thinking; HFrEF is more like HFpEF than anything else, drug classes that work in HFpEF are highly suggestive of being beneficial in the few trials we have, and we should start treating our HFpEF patients with these effective drug classes. We haven’t to date and that is why the fate of HFpEF patients, unlike their counterparts with HFrEF, has not been improved by the last two decades of treatment success in heart failure