‟Frailty, Thy Name Is Woman”: Syndrome of Women With Heart Failure With Preserved Ejection Fraction

Heart failure (HF) is the most common cause for hospitalization among patients aged ≥65 years, affecting ≈6 million Americans; at 40 years, American men and women have a 1 in 5 lifetime risk of developing HF.1 There are 2 distinct HF phenotypes: a syndrome with normal or near-normal left ventricular ejection fraction (LVEF) referred to as HF with preserved EF (HFpEF)2 and the phenotype associated with poor cardiac contractility or HF with reduced EF (HFrEF). HFrEF is frequently caused by coronary artery disease with a male predominance; evidence-based strategies have been established for more than a decade. In contrast, the precise clinical criteria for HFpEF are not universally agreed on, the syndrome disproportionally affects women in 2:1 ratio, and there are no proven treatments.3–5 There are some commonalities between HFrEF and HFpEF in addition to the classic symptoms of breathlessness, edema, and fatigue: older age, diabetes mellitus, and a history of valvular disease are risk factors that are predictive of both clinical phenotypes.6 Risk factors associated with HFpEF include female sex, especially women with diabetes mellitus,7 higher body mass index, smoking, hypertension, concentric LV hypertrophy (LVH), and atrial fibrillation (AF).6,8,9 Risk factors associated with HFrEF include male sex, higher total cholesterol and heart rate, eccentric LVH, coronary artery disease, and left bundle-branch block.6,9 A remarkable lack of consensus exists with respect to the phenotypic characteristics of HFpEF, as evidenced by the divergent definitions of the European Study Group on Diastolic Heart Failure,10 the Framingham Group,11 and the European Society of Cardiology,12 to name just a few (Table).13 All include symptoms or signs but vary in specificity and a requirement for objective data. The definition of preserved LVEF is also inconsistent …