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Heart failure with preserved ejection fraction: current management and future strategies

Expert opinion on the behalf of the Nucleus of the “Heart Failure Working Group” of the German Society of Cardiology (DKG)

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Abstract

About 50% of all patients suffering from heart failure (HF) exhibit a reduced ejection fraction (EF ≤ 40%), termed HFrEF. The others may be classified into HF with midrange EF (HFmrEF 40–50%) or preserved ejection fraction (HFpEF, EF ≥ 50%). Presentation and pathophysiology of HFpEF is heterogeneous and its management remains a challenge since evidence of therapeutic benefits on outcome is scarce. Up to now, there are no therapies improving survival in patients with HFpEF. Thus, the treatment targets symptom relief, quality of life and reduction of cardiac decompensations by controlling fluid retention and managing risk factors and comorbidities. As such, renin–angiotensin–aldosterone inhibitors, diuretics, calcium channel blockers (CBB) and beta-blockers, diet and exercise recommendations are still important in HFpEF, although these interventions are not proven to reduce mortality in large randomized controlled trials. Recently, numerous new treatment targets have been identified, which are further investigated in studies using, e.g. soluble guanylate cyclase stimulators, inorganic nitrates, the angiotensin receptor neprilysin inhibitor LCZ 696, and SGLT2 inhibitors. In addition, several devices such as the CardioMEMS, interatrial septal devices (IASD), cardiac contractility modulation (CCM), renal denervation, and baroreflex activation therapy (BAT) were investigated in different forms of HFpEF populations and some of them have the potency to offer new hopes for patients suffering from HFpEF. On the basic research field side, lot of new disease-modifying strategies are under development including anti-inflammatory drugs, mitochondrial-targeted antioxidants, new anti-fibrotic and microRNA-guided interventions are under investigation and showed already promising results. This review addresses available data of current best clinical practice and management approaches based on expert experiences and summarizes novel approaches towards HFpEF.

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Acknowledgements

European 7th Framework Consortium MEDIA (CT).

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Author notes

  1. Behrouz Kherad and Ulrich Laufs contributed equally.

Authors and Affiliations

  1. Department of Cardiology, Universitätsmedizin Berlin, Charite, Campus Rudolf Virchow Clinic (CVK), Augustenburger Platz 1, 13353, Berlin, Germany

    Carsten Tschöpe & Behrouz Kherad

  2. Berliner Zentrum für Regenerative Therapien (BCRT), Charite, Campus Virchow Clinic (CVK), Berlin, Germany

    Carsten Tschöpe

  3. Deutsches Zentrum für Herz Kreislaufforschung (DZHK), Standort Berlin/Charité, Berlin, Germany

    Carsten Tschöpe

  4. Germany Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany

    Christoph Birner & Lars Maier

  5. Innere Medizin III-Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany

    Michael Böhm

  6. Department of Cardiology and Angiology, Elisabeth Hospital, Essen, Germany

    Oliver Bruder

  7. Department of Internal Medicine III, University Halle, Halle, Germany

    Stefan Frantz

  8. Department of Internal Medicine I, Clinic St. Marien, Amberg, Germany

    Andreas Luchner

  9. Deutsches Zentrum für Herzinsuffizienz, Universitätsklinikum und Universität Würzburg, Würzburg, Germany

    Stefan Störk

  10. Privatpraxis Dr. Kherad, Berlin, Germany

    Behrouz Kherad

  11. Klinik und Poliklinik für Kardiologie im Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig, Leipzig, Germany

    Ulrich Laufs

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  1. Carsten Tschöpe
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Correspondence to Carsten Tschöpe.

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Conflict of interest

CT: Steering Committee or Speaker honoraria from AstraZeneca, Novartis, Berlin Chemie, Servier, Bristol-Meyers Squibb GmbH, Roche, Boeheringer Ingelheim, Bayer Healthcare, Impulse Dynamics. CB: Speaker honoraria from Novartis, AstraZeneca. SF: Steering Committee or Speaker honoraria from AMGEN, AstraZeneca, Bayer Vital, Boehringer Ingelheim, Bristol-Meyers Squibb GmbH, Daiichi Sankyo, MSD, Novartis, Pfizer, Servier. MB: Steering Committee, Advisory Board and Speaker honoraria from AstraZeneca, Bristol-Meyers Squibb, Boehringer Ingelheim, Medtronic, Novartis, St. Jude, Servier, Vifor. LSM: Steering Committee, Advisory Board and Speaker honoraria Gilead, Berlin-Chemie, MSD, Böhringer, Zoll, Astra-Zeneca, Novartis, Sanofi, Servier, Daiichi-Sankyo, Edwards, Bayer Healthcare, Medtronic, Pfizer, Abbott. SS: Steering committee or advisory board or speaker honoraria for AMGEN, AstraZeneca, Bayer, Berlin Chemie, Boehringer Ingelheim, Novartis, Pfizer, Servier. UL: Speaker honoraria from Amgen, Boehringer Ingelheim, MSD, Novartis, Sanofi, Servier. AL: none. BK: none. OB: none.

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Tschöpe, C., Birner, C., Böhm, M. et al. Heart failure with preserved ejection fraction: current management and future strategies. Clin Res Cardiol 107, 1–19 (2018). https://doi.org/10.1007/s00392-017-1170-6

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