Do Existing Definitions Identify Subgroup Phenotypes or Reflect the Natural History of Heart Failure With Preserved Ejection Fraction?

Over the last decennium, the definition of heart failure with preserved ejection fraction (HFpEF) has remained problematic, with lack of consensus between and among societal organizations and large outcome trials. In this issue of Circulation, the challenge of a satisfactory HFpEF definition is highlighted by the application of 7 existing HFpEF definitions to a single-center study sample of patients presenting with dyspnea (New York Heart Association class II–IV) and preserved left ventricular (LV) ejection fraction (>50%).1 The 7 existing definitions included 3 societal HFpEF definitions based on expert consensus (American College of Cardiology/ American Heart Association [ACC/AHA] 2013, European Society of Cardiology 2016, and Heart Failure Society of America 2010) and 4 sets of HFpEF trial entry criteria geared mostly toward maximizing outcome events (I-PRESERVE [Irbesartan in Heart Failure With Preserved Ejection Fraction Study], RELAX [Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in Heart Failure With Preserved Ejection Fraction], TOPCAT [Treatment of Preserved Cardiac function in Heart Failure With Aldosterone Antagonist], PARAGON [Prospective Comparison of ARNI With ARB Global Outcome in HF With Preserved Ejection Fraction]). Given the uncertainties and controversies on how to define HFpEF, the authors also included a pathophysiological approach with HFpEF defined by elevated LV filling pressures during exercise. The authors defined HFpEF as elevated pulmonary artery wedge pressure at rest or during exercise, thus complementing the 7 existing HFpEF definitions with thorough hemodynamic data. The authors are to be commended for their efforts.