Prof Filippo Crea, Catholic University of Rome, Italy

Filippo Crea, Professor of Cardiology in the Catholic University of Rome, Italy, talks to Cardio Debate about HF-PEF and coronary artery spasm.


What is HF-PEF?
HF-pEF is Heart Failure with Preserved Ejection Fraction. This is an interesting syndrome because for many years we thought heart failure is when you have reduced ejection fraction, or a severe valve disease.

In the past few years we have been learning that about 50 per cent of patients with heart failure, they do not have reduced ejection fraction – which was supposed to be the hallmark of heart failure – nor valve disease. In these patients ejection fraction is normal, yet these patients have the same symptoms as the patients with heart failure with reduced ejection fraction.

And what we have been learning is that the outcome of these patients is a bit better than that of patients with reduced ejection fraction but definitely much worse than that in subjects without heart failure.

What are the mechanisms?
The mechanisms are mainly related to the fact that the amount of fibrosis in the heart increases. This makes the heart stiffer and this is the cause of symptoms and the cause of the alterations we can pick up on echocardiography.

Echocardiography in these patients is characterized by LVH (left ventricular hypertrophy) or impaired diastolic function, or atrial enlargement. And the diagnosis of HF-pEF is based on these situations – firstly symptoms and signs of heart failure, and then changes on echocardiography characterized again by LVH, dilated atria or impaired diastolic function. When these things come together we have the diagnosis of heart failure with preserved ejection fraction where the main issue is a sort of “stiff” heart.

What are the treatments?
Definitely this is an unmet need because so far no treatment has been found to improve the outcome of patients with HF-pEF. And also we don’t have a validated treatment able to improve symptoms in these patients with HF-pEF.

Of course we have a wide array of drugs that can be used, but no treatment has been found to systematically improve symptoms. So the treatment, the symptomatic treatment of these patients, is very empirical. We have to start with drugs that are likely to work, and if they don’t work we have to try other drugs. And, eventually, in the vast majority of these patients we get some improvement of symptoms.

As for the outcome, many drugs have been tested in order to improve the outcome for these patients. But, really, we so far don’t have a success story.