Heart failure (HF) is a complex clinical syndrome characterized by the inability of the heart to pump blood adequately to meet the metabolic demands of the body. Traditionally, HF has been classified into two major categories: heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). While HFrEF has long been the focus of clinical research and therapeutic advances, HFpEF has emerged as a distinct and increasingly prevalent entity, accounting for nearly half of all HF cases worldwide.

HFpEF is defined by the presence of typical symptoms and signs of heart failure, such as dyspnea, fatigue, and fluid retention, in the setting of a preserved left ventricular ejection fraction (≥50%). Unlike HFrEF, where systolic dysfunction predominates, HFpEF is characterized by diastolic dysfunction, impaired ventricular relaxation, increased myocardial stiffness, and elevated filling pressures. These pathophysiological changes lead to congestion and reduced exercise tolerance despite normal systolic function.

Global Burden and Epidemiology

The prevalence of HFpEF has risen steadily over the past two decades, largely due to aging populations, improved survival from ischemic heart disease, and the growing burden of comorbidities such as hypertension, diabetes mellitus, obesity, and chronic kidney disease. Epidemiological studies suggest that HFpEF is more common in women and elderly individuals, with significant regional variations. In Asian populations, including India, the prevalence of HFpEF is particularly high, reflecting the widespread occurrence of hypertension and diabetes.

Clinical Significance

HFpEF is not a benign condition. Patients experience frequent hospitalizations, reduced quality of life, and mortality rates comparable to those with HFrEF. Despite preserved systolic function, the morbidity associated with HFpEF is substantial, and therapeutic options remain limited. Current management strategies focus primarily on controlling comorbidities and alleviating symptoms, as no pharmacological therapy has yet demonstrated a clear mortality benefit in HFpEF.

Pathophysiology

The pathophysiology of HFpEF is multifactorial and involves structural, functional, and molecular changes. Chronic hypertension leads to left ventricular hypertrophy and increased myocardial stiffness. Diabetes and obesity contribute to systemic inflammation, endothelial dysfunction, and myocardial fibrosis. Aging itself is associated with reduced ventricular compliance and impaired relaxation. Together, these factors culminate in elevated left atrial pressures, pulmonary congestion, and exercise intolerance.

Rationale for the Study

Given the rising prevalence and clinical impact of HFpEF, it is essential to characterize the clinical profile and risk factors in diverse populations. Tertiary care hospitals serve as referral centers for complex cases and provide an opportunity to study HFpEF in patients with multiple comorbidities. Identifying the demographic and clinical characteristics of HFpEF patients can help in tailoring preventive and therapeutic strategies.

Aim of the Study

The present study was conducted to evaluate the clinical profile and risk factors of HFpEF among 155 patients admitted to a tertiary care hospital. By analyzing demographic data, clinical presentation, comorbidities, and echocardiographic findings, this study aims to contribute to the growing body of evidence on HFpEF and highlight the importance of early detection and comprehensive management.

Study Design & Setting: A single-centre, hospital-based cross-sectional observational study was carried out at a tertiary care facility

Study Design: Retrospective observational study.

Sample Size Based on feasibility and available patient records, a total of 155 consecutive eligible patients were enrolled during the study period. Chronic HF was diagnosed according to European Society of Cardiology (ESC) guideline recommendations. Diagnosis required the presence of typical HF symptoms and/or signs, together with objective evidence of cardiac structural and/or functional abnormality on transthoracic echocardiography. N-terminal pro B-type natriuretic peptide (NT-proBNP) levels were used as supportive biomarkers where available. Patients were subsequently classified according to left ventricular ejection fraction (LVEF) into.

Inclusion Criteria: Adults ≥18 years, EF ≥50%, clinical features of HF (NYHA II–IV).

• Patients were eligible for enrollment if they met the following conditions:
• Age ≥18 years at the time of presentation.
• Established diagnosis of chronic heart failure (HF) according to European Society of Cardiology (ESC) guideline recommendations.
• Clinically stable at the time of enrollment (no acute decompensation or hospitalization for HF within the preceding four weeks).
• Presence of typical HF symptoms and/or signs, such as dyspnea, fatigue, orthopnea, paroxysmal nocturnal dyspnea, or peripheral edema.
• Objective evidence of cardiac structural and/or functional abnormality on transthoracic echocardiography (e.g., left atrial enlargement, left ventricular hypertrophy, diastolic dysfunction).
• Left ventricular ejection fraction (LVEF ≥50%) for classification into HFpEF.
• Written informed consent obtained prior to participation.

Exclusion Criteria: Patients with reduced EF, congenital heart disease, valvular heart disease, or incomplete records.

• Acute decompensated HF
• Cardiogenic shock
• Recent hospitalization for HF within the preceding four weeks
• Severe valvular heart disease requiring immediate surgical or interventional correction
• Advanced non-cardiac terminal illnesses (e.g., advanced chronic kidney disease requiring dialysis, active malignancy with limited life expectancy)
• Patients unwilling to provide informed consent

Data Collection: Demographics, clinical presentation, comorbidities, laboratory values, echocardiographic findings.

Statistical Analysis: Statistical analysis was performed using STATA version 12. Continuous variables are presented as mean ± SD or median (range), as appropriate, and categorical variables as n (%). Comparisons of continuous variables between HF phenotypes (HFrEF, HFmrEF, and HFpEF) were performed using one-way analysis of variance (ANOVA) for normally distributed data and the Kruskal–Wallis test for non-normally distributed data. A two-sided P-value <0.05 was considered statistically significant.

Demographic Characteristics

A total of 155 patients with heart failure were enrolled in the study. The mean age of the cohort was 62.4 ± 11.2 years, with the majority belonging to the elderly age group (>60 years). There was a female predominance (60%), consistent with the epidemiological trend of HFpEF being more common in women. Most patients were from urban areas (65.2%), while 34.8% resided in rural regions.

Clinical Presentation

The most frequent presenting symptom was dyspnea, reported by 121 patients (78.1%), predominantly in NYHA functional class II–III. Fatigue was observed in 65.2% of patients, while peripheral edema was present in 41.9%. Orthopnea and paroxysmal nocturnal dyspnea were noted in 27.7%, and palpitations in 18.1%. These findings highlight the predominance of exertional breathlessness and reduced exercise tolerance as hallmark features of HFpEF.

Risk Factor Profile

Hypertension was the most prevalent comorbidity, affecting 72.3% of patients. Diabetes mellitus was present in 58.1%, while obesity (BMI >30) was documented in 40%. Other notable risk factors included dyslipidemia (36.1%), coronary artery disease (27.7%), and chronic kidney disease (14.8%). The clustering of metabolic risk factors underscores the strong association between HFpEF and systemic comorbidities.

Echocardiographic Findings

All patients had preserved left ventricular ejection fraction (≥50%). Left atrial enlargement was observed in 47.7%, while left ventricular hypertrophy was present in 52.3%. Diastolic dysfunction (Grade II–III) was documented in 67.1% of patients, confirming the pathophysiological hallmark of HFpEF. Pulmonary hypertension was noted in 21.9%, reflecting advanced disease in a subset of patients.

Laboratory and Electrocardiographic Parameters

The mean hemoglobin level was 12.1 ± 1.8 g/dL, with mild anemia observed in several patients. NT-proBNP levels, available in 120 patients, averaged 865 ± 320 pg/mL, supporting the diagnosis of HF. On electrocardiography, left ventricular hypertrophy patterns were seen in 37.4%, atrial fibrillation in 18.7%, and normal sinus rhythm in 62.6%. The presence of atrial fibrillation highlights its role as both a consequence and contributor to HFpEF.

Table 1. Demographic Characteristics of Patients (N=155)

Table 2. Clinical Presentation at Admission

Table 3. Distribution of Risk Factors

Table 4. Echocardiographic Findings

Table 5. Laboratory and ECG Parameters

This study highlights the predominance of HFpEF among elderly females, consistent with global epidemiological data. Hypertension emerged as the most significant risk factor, followed by diabetes and obesity. These findings align with the Framingham Heart Study and Asian cohort studies.

The pathophysiology of HFpEF involves increased ventricular stiffness, impaired relaxation, and elevated filling pressures. Comorbidities such as diabetes and obesity exacerbate myocardial fibrosis and microvascular dysfunction.

Clinical implications include the need for aggressive control of hypertension, diabetes, and weight management. Unlike HFrEF, pharmacological options for HFpEF remain limited, emphasizing the importance of lifestyle modification and comorbidity management.

Our findings underscore the necessity of multidisciplinary care, including cardiology, endocrinology, and nephrology, to optimize outcomes.

RISK FACTOR ANALYSIS

HYPERTENSION- In our study hypertension was found as a risk factor in 64.76% of patients. It was the commonest risk factor for HFpEF found in this study. Similar results were found in western studies conducted Chronically increased blood pressure is an important stimulus for cardiac structural remodeling and functional changes. The resultant hypertensive heart disease is characterized by LV hypertrophy (LVH), increasing vascular and ventricular systolic stiffness, impaired relaxation, and increased diastolic stiffness, all factors linked to the pathogenesis of HFpEF.

DIABETES- In our study diabetes mellitus was found as a risk factor in 33.3% of patients. It was the second most common risk factor for HFpEF found in this study. In the study by Bursi et al  found that 36% patients with HFpEF had diabetes mellitus. Similar result was found in a study conducted by Bhatia et al8 where diabetes mellitus was found in 32% patients. Mechanisms contributing to structural and functional coronary vascular and myocardial changes are diverse and include metabolic disturbances, activation of proinflammatory and profibrotic mediators, cardiac autonomic neuropathy, and increases in advanced glycation end-products (AGE), which promote increased collagen accumulation and age-related cardiovascular stiffening.

OBESITY- In our study obesity (BMI more than 30 kg/m2) was found as a risk factor in 28.35% patients with HFpEF. Mean BMI in our study was 25.44kg/m2. In a study by Owan et al17 41% of patient with HFpEF had obesity. Mean BMI in a similar study done in the US7 was 29.6kg/m2 which is comparable to our study since for the same amount of body fat, age and sex Indians tend to have a consistently lower BMI by 2-3kg/m2 due to difference in body build and masculinity.

CORONARY ARTERY DISEASE - In our study, coronary artery disease was found as a risk factor in 23.80% of patient with HFpEF. In study by Bursi et al, found coronary artery disease as a risk factor in 36% patient with HFpEF. Acute and chronic Ischemia is known to cause Diastolic dysfunction and is the leading cause of HF in both Reduced and preserved EF.

ATRIAL FIBRILLATION - In our study we found Atrial fibrillation (AF) in 21% patients as a risk factor for HFpEF. Similar result was found in a study by Bursi et al, where AF was present in 31% of patients of HFpEF.. AF may cause decompensated HF in patients with diastolic dysfunction and diastolic dysfunction itself is a risk factor for atrial fibrillation. Thus, diastolic dysfunction, atrial fibrillation, and HFpEF are common and related conditions that probably share common pathogenic mechanisms, particular in the elderly.

Our study on Heart Failure with Preserved Ejection Fraction (HFpEF) highlights that it primarily affects older adults, with common symptoms including dyspnoea and fatigue. Hypertension and diabetes are prevalent comorbidities. Although ejection fraction remains normal, diastolic function is often impaired, with most patients showing mild dysfunction. Dyslipidaemia is common but less so than hypertension and diabetes. These findings emphasize the need for comprehensive management of symptoms and comorbidities, and further research is needed to enhance treatment strategies.

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