Practice Uncertainties Page

Should treatment for heart failure with preserved ejection fraction differ from that for heart failure with reduced ejection fraction?

BMJ 2010; 341 doi: (Published 25 August 2010) Cite this as: BMJ 2010;341:c4202
  1. Philip Jong, research fellow ,
  2. Robert McKelvie, professor of medicine ,
  3. Salim Yusuf, professor of medicine and director of Population Health Research Institute
  1. 1Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada
  1. Correspondence to: S Yusuf yusufs{at}

    Heart failure with preserved ejection fraction (HF-PEF) accounts for about half of all cases of heart failure.1 Population based studies have shown that patients with HF-PEF have high rates of mortality (20-30% risk at one year)2 3 and readmission to hospital (30% risk at 60-90 days),4 which are similar to the rates for patients with heart failure with reduced ejection fraction (HF-REF). When compared with patients with HF-REF, those with HF-PEF are older, more often female, and more likely to have hypertension and atrial fibrillation, but are less likely to have coronary artery disease.2 3 Identifying patients with HF-PEF can be difficult, however, because heart failure presents in many different ways and the diagnostic criteria that define this syndrome are complex.5 The guideline from National Institute for Health and Clinical Excellence has proposed detailed guidance on diagnosis.6 In practice, the diagnosis of HF-PEF is often made in patients with symptoms and signs of heart failure who have preserved left ventricular ejection fraction. Furthermore, the evidence that supports treatment for HF-PEF is much weaker than that supporting treatment for HF-REF. To date, results from existing clinical trials of HF-PEF have been largely inconclusive, and treatments that have been shown to reduce morbidity and mortality in patients with HF-REF showed either no or only marginal benefits in patients with HF-PEF.

    What is the evidence of the uncertainty?

    To clarify whether treatments that are beneficial in HF-REF may also be beneficial in HF-PEF, we searched Medline, Embase, and the Cochrane Library for all adequately powered randomised controlled trials of treatments for chronic heart failure (HF-PEF or HF-REF) that had reported both mortality and admission to hospital as their primary outcomes. We found no meta-analyses of treatments for HF-PEF, so we depended on studies that would provide the most robust and unbiased estimates of the …

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