During a recent PW Podcast episode, we spoke with Marc Bonaca, MD, MPH, Executive Director of CPC Clinical Research; and Associate Professor in the Division of Cardiology, Director of Vascular Research, and William R. Hiatt Endowed Chair in Cardiovascular Research at the University of Colorado School of Medicine. Following is a summary of that interview:

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What do we know about heart failure with preserved ejection fraction?

Heart failure is growing in prevalence and is common in the setting of coronary artery disease, but a large and growing patient population has heart failure with preserved ejection fraction (HFpEF), which results in symptoms that are characteristic of heart failure. It is more common in female patients, with gender-specific factors that may be related. Other risk factors include age—because as we age, the heart muscle stiffens—and different vasculature. HFpEF is also more common in those with obesity, diabetes, and sleep apnea.

Recognition is important, particularly in patients with diabetes, older patients, and women, where we find that it is underdiagnosed. When patients report symptoms like dyspnea on exertion, it is important to no discount them and understand that patients may under-report those symptoms with thinking it is just part of getting older. Understanding why they have these symptoms is important, and examination can be helpful. Often, echocardiograms do not help, because their ejection fraction is normal or could be high because the chamber size is small and relatively under-filled. That patient may have symptoms related to heart failure. Once HFpEF is recognized, diagnosing it and treating all the risk factors with guidelinedirected medical therapy is critical.

The search for HFpEF therapies has been more challenging than that for traditional HF with reduced ejection fraction, but there are novel therapies available, as well as many ongoing trials to try to understand how to treat HFpEF. Initially developed for treating diabetes, the SGLT2 inhibitors have been shown to not only reduce HF and cardiovascular death in patients with diabetes, but they also have been shown to benefit patients without diabetes with HFpEF. The DECLARE-TIMI 58 trial of patients with diabetes and HFpEF showed a reduction in HF hospitalizations with an SGLT2 inhibitor. Ongoing trials are also assessing the effects of SGLT2 inhibitors and agents with other mechanisms on 6-minute walking distance and other patient-reported outcome measures. Over the next several years, I think we hopefully will have more therapies to turn to for HFpEF.

Patients should be informed that even if they do not have coronary artery disease or they have not had a heart attack, that as they age, if they have diabetes or obesity or are female and start noticing shortness of breath, swelling in the legs, or other symptoms, to not dismiss them and make sure they discuss them with their physician. Control of blood pressure, treatment of sleep apnea, and treatment of obesity, for example, can help attenuate the development or progression of HFpEF.