Heart Failure With Preserved Ejection Fraction, a Surrogate for Comorbidity?
For years, clinical studies on HFpEF have been most frustrating. The concepts for treating heart failure with reduced ejection fraction generally have failed in large HFpEF trials. Prevalence of HFpEF seems to rise in our aging society and patients appear to become more and more multimorbid. Two latest studies may exemplify the problem. The aldosterone antagonist spironolactone showed some benefit on left ventricular diastolic function in the Aldo-DHF study but did not reduce the combined cardiovascular primary outcome in the TOPCAT trial (late breaking session at AHA 2013). The RELAX study, testing the effect of the phosphodiesterase-5 inhibitor sildenafil, was completely negative. In the RELAX trial, 43% had diabetes mellitus, 19% COPD, 51% atrial fibrillation or flutter, and 35% anaemia. In the Aldo-DHF study, comorbidities were present but prevalence was somewhat lower (diabetes: 17%, COPD: 3%, a trial fibrillation: 5%, average Hb: 13.8 g/dL). Nevertheless, comorbidities may dominate the course of heart failure and may thus defeat potential benefit of a cardiovascular approach of therapy. In this clinical syndrome, physical exercise could be an attractive alternative to drugs since it may have beneficial effects on HFpEF as well as on various comorbidities.