Challenges in the diagnosis of heart failure with preserved ejection fraction in individuals with obesity

Mineralocorticoid Receptor Antagonists in Heart Failure with Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

Background/Objectives: Heart failure with preserved ejection fraction (HFpEF) is a complex clinical syndrome with limited therapeutic options. Mineralocorticoid receptor antagonists (MRAs) have been shown to improve clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF), but their use in patients with HFpEF remains controversial. The aim of this review is to evaluate whether the use of MRAs improves diastolic function, functional capacity, and quality of life in patients with HFpEF. Methods: A systematic literature search of scientific databases was performed to identify studies comparing the use of MRAs to placebo or no treatment in adult patients with HFpEF (2000-2024; English; PROSPERO registration CRD42022300783). Data were meta-analysed using a random-effects model for overall effect size measured as the standardised mean difference. Results: Pooled data revealed a significant benefit of MRA use compared to the control in decreasing E/e' (SMD -0.21; 95% CI: -0.33 to -0.10, p = 0.00), with greater improvement seen with longer duration of treatment. A substantial reduction in systolic blood pressure (SMD -0.27; 95% CI: -0.53 to -0.02, p = 0.03) and diastolic blood pressure (SMD -0.18; 95% CI: -0.32 to -0.04, p = 0.01) was also noted. There was no significant difference in the 6 min walk distance, peak exercise capacity, or quality-of-life measures. Adverse events such as hyperkalaemia and worsening renal function were frequently reported in the MRA group. Conclusions: MRAs improve echocardiographic parameters of diastolic function and BP control; however, this did not translate into clinical outcomes of improved functional capacity or quality of life.

Insights Into the Role of Obesity in Heart Failure With Preserved Ejection Fraction Pathophysiology and Management

Heart failure (HF) is a significant global health issue, categorized by left ventricular ejection fraction, being either reduced (HFrEF < 0.40) or preserved (HFpEF > 0.50), or in the middle of this range. Although the overall incidence of HF remains stable, HFpEF cases are increasing, representing about 50% of all HF cases. Outcomes for HFpEF are similar to those for HFrEF, leading to substantial health-care resource use. Despite extensive research over the past 2 decades, the prognosis and mortality rates for HFpEF remain high. A key feature of HFpEF is exercise intolerance, characterized by severe exertional dyspnea and fatigue, which significantly impacts quality of life. The underlying mechanisms of exercise intolerance are not fully understood due to the complex pathophysiology and multisystem involvement. Obesity is a common comorbidity in HFpEF, especially in North America, leading to worsening symptoms, hemodynamics, and mortality rates. Increased adiposity leads to inflammation, hypertension, dyslipidemia, and insulin resistance, and impairing cardiac, vascular, pulmonary, and skeletal muscle function. Therefore, managing obesity is crucial in treating HFpEF. In this review we explore the pathophysiologic mechanisms of HFpEF, emphasizing obesity's role, and we discuss current management strategies while identifying areas needing further research.