Comorbidities and differential diagnosis in heart failure with preserved ejection fraction

Heart failure ( HF ) is common, affecting 1% to 2% of the general population,1–3with the prevalence rising to more than 10% in those aged more than 80 years.1,4 HF has a high morbidity and reduced life expectancy, with 5- and 10-year survival rates of 50% and 10% reported in epidemiologic studies.5,6 HF can broadly be divided into 2 groups: HF with reduced ejection fraction ( HF-REF ) and HF with preserved ejection fraction ( HF-PEF ). There is a suggestion that HF-PEF accounts for almost half of all patients with HF and that prognosis is equally poor between groups,7,8 although a recent meta-analysis of 41,972 patients showed HF-REF to have a worse prognosis.9 The main difference between these 2 groups is response to treatment. Where HF-REF has several evidence-based therapies proved to improve survival, no treatment has been shown to do so in HF-PEF. The HF-PEF phenotype also differs from HF-REF, with HF-PEF patients being older, more often women, obese, and with more comorbidities. HF-PEF diagnosis is challenging and essentially a diagnosis of exclusion, with comorbidities potentially making the diagnosis more difficult. This article describes the comorbidities commonly associated with HF-PEF, the potential influence of these comorbidities on morbidity and mortality, and the differential diagnosis.