Intended for healthcare professionals

Practice Uncertainties

How big a problem is heart failure with a normal ejection fraction?

BMJ 2016; 353 doi: (Published 18 April 2016) Cite this as: BMJ 2016;353:i1706
  1. Frans H Rutten, associate professor of general practice1,
  2. Andrew L Clark, professor of clinical cardiology2,
  3. Arno W Hoes, professor of clinical epidemiology and general practice1
  1. 1Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
  2. 2Department of Cardiology, Hull York Medical School, University of Hull, Castle Hill Hospital, Cottingham, UK
  1. Correspondence to: F H Rutten f.h.rutten{at}

What you need to know

  • There is variation in the thresholds for diagnosing heart failure with a normal ejection fraction

  • Treatment of heart failure with normal ejection fraction does not improve survival: however, offer symptom relief with diuretics and treat hypertension and other comorbidities

  • Further research is needed to characterise normal echocardiography in the ageing heart and to understand better the natural history of heart failure with a normal ejection fraction

Much uncertainty exists around heart failure with a normal ejection fraction, beginning with its diagnosis; there are no clinical features that distinguish it from heart failure with reduced ejection fraction.1 2 On echocardiography the filling capacity of the left ventricle can at best be measured only indirectly. Estimates of the prevalence of heart failure with a normal ejection fraction and its prognosis vary. Doubt exists about the clinical relevance of the diagnosis of heart failure with a normal ejection fraction because no treatment to date has substantially improved prognosis. Management is focused on symptom reduction and blood pressure control.1 2

Our preferred term is heart failure with normal ejection fraction. However the term is used interchangeably with “preserved ejection fraction” or diastolic heart failure. These seem less accurate because “preserved” suggests prior measurement of the patient’s ejection fraction before the development of symptoms, which is not generally the case. “Diastolic” heart failure implies that systolic function is unaffected, which is incorrect.

What is the evidence of the uncertainty?

How is heart failure with normal ejection fraction diagnosed?

A diagnosis of heart failure requires a combination of clinical features—such as breathlessness, fatigue, and ankle oedema—together with a structural or functional abnormality of the heart that impairs its ability to pump on echocardiography.1 Pump failure is typically caused by reduced contraction of the left ventricle, measured as a reduced ejection fraction. Reduced ejection fraction is almost always accompanied by impaired filling of the left ventricle, but in some patients …

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