Table 2.

Principal clinical and pathophysiological characteristics of inflammatory‐metabolic heart failure with a preserved ejection fraction

• Exertional dyspnoea due to heart failure with a left ventricular ejection fraction that is generally >40%

• Primarily a disease of women

• Generally accompanied by a chronic systemic inflammatory or metabolic disorder that is characterized by a derangement of adipose tissue biology (e.g. obesity, diabetes, metabolic syndrome, non‐alcoholic fatty liver disease, rheumatoid arthritis, psoriasis)

• Increased biomarkers reflecting systemic inflammation or insulin resistance (e.g. C‐reactive protein)

• Mildly increased systolic blood pressure or taking medications for the treatment of hypertension

• Echocardiography reveals normal to modestly increased left ventricular volumes (indexed for gender and body surface area), generally with diastolic filling abnormalities, but without marked septal thickening

• Magnetic resonance imaging demonstrates increased epicardial adipose tissue volume, with variable degrees of fibrosis

• Coronary microvascular dysfunction, ideally measured by reduced coronary flow reserve during adenosine‐induced hyperaemia, but approximated by provocative testing during non‐invasive imaging

• Renal dysfunction (typically, an estimated glomerular filtration rate of 50–80 mL/min/1.73 m2), with evidence of increased perirenal fat or renal microvascular disease related to systemic inflammation

• Potentially impaired systemic venous capacitance (often with plasma volume expansion) leading to an increase in central blood volume

• Potential reduction in adverse heart failure‐related outcomes with mineralocorticoid receptor antagonists and neprilysin inhibitors