HEART FAILURE WITH PRESERVED EJECTION FRACTION: THE CENTRAL ROLE OF LIFESTYLE MODIFICATION AND NONPHARMACOLOGICAL THERAPIES
DOI:
https://doi.org/10.31435/ijitss.1(49).2026.5545Keywords:
Heart Failure, Lifestyle Modification, Exercise Training, Obesity, Vagus Nerve StimulationAbstract
Introduction: Heart failure with preserved ejection fraction (HFpEF) is a condition characterized by significant morbidity and mortality, as well as a considerable burden on healthcare systems. Until recently, sodium-glucose co-transporter 2 (SGLT2) inhibitors were the only drug class to demonstrate a consistent benefit in clinical outcomes among these patients. HFpEF is a complex, multifactorial disorder frequently associated with advanced age, obesity, hypertension, diabetes, and sedentary lifestyle. Many of these risk factors are potentially modifiable.
Aim of the Study: The aim of this article is to provide a comprehensive overview of the role of nonpharmacological interventions and lifestyle modifications in the management of HFpEF, emphasizing current evidence for their effectiveness and highlighting the importance of patient-centered, multidisciplinary approaches in improving clinical outcomes.
Materials and Methods: A thorough review of the literature was conducted using the PubMed database, Google Scholar with search terms including “heart failure with preserved ejection fraction”, “HFpEF treatment”, “lifestyle modification”, “obesity”, “diet”, “exercise”, vagus nerve stimulation” and related keywords.
Results and Conclusions: Nonpharmacological interventions, including exercise training, dietary modification, weight management, and patient education, have demonstrated significant benefits in improving functional capacity, quality of life, and cardiovascular risk profiles in patients with HFpEF. Although pharmacological treatment options remain limited, lifestyle-based strategies are essential components of comprehensive care for this population. Future research should continue to refine and personalize nonpharmacological approaches to further improve outcomes for individuals living with HFpEF.
References
Khan, M. S., Shahid, I., Bennis, A., Rakisheva, A., Metra, M., & Butler, J. (2024, October). Global epidemiology of heart failure. Nature Reviews Cardiology, 21(10), 717–734. https://doi.org/10.1038/s41569-024-01046-6
Dunlay, S. M., Roger, V. L., & Redfield, M. M. (2017, October 1). Epidemiology of heart failure with preserved ejection fraction. Nature Reviews Cardiology. https://doi.org/10.1038/nrcardio.2017.65
Lippi, G., & Sanchis-Gomar, F. (2020, June). Global epidemiology and future trends of heart failure. AME Medical Journal, 5, 15–15. https://doi.org/10.21037/amj.2020.03.03
Yang, C., et al. (2025, January). Global, regional, and national burdens of heart failure in adolescents and young adults aged 10–24 years from 1990 to 2021: An analysis of data from the Global Burden of Disease Study 2021. EClinicalMedicine, 79, Article 102998. https://doi.org/10.1016/j.eclinm.2024.102998
McDonagh, T. A., et al. (2021, September). 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. European Heart Journal, 42(36), 3599–3726. https://doi.org/10.1093/eurheartj/ehab368
Pandey, A., et al. (2018). Sex and race differences in lifetime risk of heart failure with preserved ejection fraction and heart failure with reduced ejection fraction. Circulation, 137(17), 1814–1823. https://doi.org/10.1161/CIRCULATIONAHA.117.031622
Fudim, M., et al. (2020, June). Trends in treatment for patients hospitalized with heart failure with preserved ejection fraction before and after Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT). The American Journal of Cardiology, 125(11), 1655–1660. https://doi.org/10.1016/j.amjcard.2020.02.038
Massie, B. M., et al. (2008, December). Irbesartan in patients with heart failure and preserved ejection fraction. The New England Journal of Medicine, 359(23), 2456–2467. https://doi.org/10.1056/NEJMoa0805450
Yusuf, S., et al. (2003, September). Effects of candesartan in patients with chronic heart failure and preserved left-ventricular ejection fraction: The CHARM-Preserved trial. The Lancet, 362(9386), 777–781. https://doi.org/10.1016/S0140-6736(03)14285-7
Cleland, J. G. F. (2006, October). The perindopril in elderly people with chronic heart failure (PEP-CHF) study. European Heart Journal, 27(19), 2338–2345. https://doi.org/10.1093/eurheartj/ehl250
Solomon, S. D., et al. (2019, October). Angiotensin–neprilysin inhibition in heart failure with preserved ejection fraction. The New England Journal of Medicine, 381(17), 1609–1620. https://doi.org/10.1056/NEJMoa1908655
Anker, S. D., et al. (2021, October). Empagliflozin in heart failure with a preserved ejection fraction. The New England Journal of Medicine, 385(16), 1451–1461. https://doi.org/10.1056/NEJMoa2107038
Solomon, S. D., et al. (2022, September). Dapagliflozin in heart failure with mildly reduced or preserved ejection fraction. The New England Journal of Medicine, 387(12), 1089–1098. https://doi.org/10.1056/NEJMoa2206286
Savarese, G., & Lund, L. H. (2017). Global public health burden of heart failure. Cardiac Failure Review, 3(1), 7. https://doi.org/10.15420/cfr.2016:25:2
Owan, T. E., Hodge, D. O., Herges, R. M., Jacobsen, S. J., Roger, V. L., & Redfield, M. M. (2006, July). Trends in prevalence and outcome of heart failure with preserved ejection fraction. The New England Journal of Medicine, 355(3), 251–259. https://doi.org/10.1056/NEJMoa052256
Campbell, P., Rutten, F. H., Lee, M. M., Hawkins, N. M., & Petrie, M. C. (2024, March 16). Heart failure with preserved ejection fraction: Everything the clinician needs to know. The Lancet. https://doi.org/10.1016/S0140-6736(23)02756-3
Tang, F., et al. (2024, August). Nonpharmacological approaches to managing heart failure with preserved ejection fraction. Circulation: Heart Failure, 17(8), e011269. https://doi.org/10.1161/CIRCHEARTFAILURE.123.011269
Anker, S. D., et al. (2023, July). Patient phenotype profiling in heart failure with preserved ejection fraction to guide therapeutic decision making. A scientific statement of the Heart Failure Association, the European Heart Rhythm Association of the European Society of Cardiology, and the European Society of Hypertension. European Journal of Heart Failure, 25(7), 936–955. https://doi.org/10.1002/ejhf.2894
Heidenreich, P. A., et al. (2022, May). 2022 AHA/ACC/HFSA guideline for the management of heart failure. Journal of the American College of Cardiology, 79(17), e263–e421. https://doi.org/10.1016/j.jacc.2021.12.012
Nagueh, S. F., et al. (2016, April). Recommendations for the evaluation of left ventricular diastolic function by echocardiography: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography, 29(4), 277–314. https://doi.org/10.1016/j.echo.2016.01.011
Paulus, W. J., & Tschöpe, C. (2013, July 23). A novel paradigm for heart failure with preserved ejection fraction: Comorbidities drive myocardial dysfunction and remodeling through coronary microvascular endothelial inflammation. Journal of the American College of Cardiology. https://doi.org/10.1016/j.jacc.2013.02.092
Daou, D., Gillette, T. G., & Hill, J. A. (2023, September 1). Inflammatory mechanisms in heart failure with preserved ejection fraction. Physiological Reviews. https://doi.org/10.1152/physiol.00004.2023
Paulus, W. J., & Zile, M. R. (2021, May). From systemic inflammation to myocardial fibrosis: The heart failure with preserved ejection fraction paradigm revisited. Circulation Research, 128(10), 1451–1467. https://doi.org/10.1161/CIRCRESAHA.121.318159
Franssen, C., et al. (2016, April). Myocardial microvascular inflammatory endothelial activation in heart failure with preserved ejection fraction. JACC: Heart Failure, 4(4), 312–324. https://doi.org/10.1016/j.jchf.2015.10.007
Mishra, S., Chander, V., & Kass, D. A. (2024, February 1). Cardiac cGMP regulation and therapeutic applications. Hypertension. https://doi.org/10.1161/HYPERTENSIONAHA.124.21709
LeWinter, M. M., & Meyer, M. (2013, November). Mechanisms of diastolic dysfunction in heart failure with a preserved ejection fraction. Circulation: Heart Failure, 6(6), 1112–1115. https://doi.org/10.1161/CIRCHEARTFAILURE.113.000825
Fayyaz, A. U., et al. (2024, February 1). Pathophysiological insights into HFpEF from studies of human cardiac tissue. Nature Reviews Cardiology. https://doi.org/10.1038/s41569-024-01067-1
Jia, F., Chen, A., Zhang, D., Fang, L., & Chen, W. (2022, July). Prognostic value of left atrial strain in heart failure: A systematic review and meta-analysis. Frontiers in Cardiovascular Medicine, 9. https://doi.org/10.3389/fcvm.2022.935103
Floras, J. S., & Ponikowski, P. (2015, August). The sympathetic/parasympathetic imbalance in heart failure with reduced ejection fraction. European Heart Journal, 36(30), 1974–1982. https://doi.org/10.1093/eurheartj/ehv087
Florea, V. G., & Cohn, J. N. (2014, May 23). The autonomic nervous system and heart failure. Circulation Research. https://doi.org/10.1161/CIRCRESAHA.114.302589
Grassi, G., et al. (2009, February). Sympathetic and baroreflex cardiovascular control in hypertension-related left ventricular dysfunction. Hypertension, 53(2), 205–209. https://doi.org/10.1161/HYPERTENSIONAHA.108.121467
Thompson, S. L., et al. (2021, July 13). A review of parameter settings for invasive and non-invasive vagus nerve stimulation (VNS) applied in neurological and psychiatric disorders. Frontiers in Neuroscience. https://doi.org/10.3389/fnins.2021.709436
Zhou, L., et al. (2019, January). Low-level transcutaneous vagus nerve stimulation attenuates cardiac remodelling in a rat model of heart failure with preserved ejection fraction. Experimental Physiology, 104(1), 28–38. https://doi.org/10.1113/EP087351
DiCarlo, L. A., et al. (2018, February). Autonomic regulation therapy to enhance myocardial function in heart failure patients: The ANTHEM-HFpEF study. ESC Heart Failure, 5(1), 95–100. https://doi.org/10.1002/ehf2.12241
Stavrakis, S., Elkholey, K., Morris, L., Niewiadomska, M., Asad, Z. U. A., & Humphrey, M. B. (2022, February). Neuromodulation of inflammation to treat heart failure with preserved ejection fraction: A pilot randomized clinical trial. Journal of the American Heart Association, 11(3). https://doi.org/10.1161/JAHA.121.023582
Nagai, M., Dote, K., Kato, M., Sasaki, S., Oda, N., & Förster, C. Y. (2022, September). Case report: SGLT2i, transcutaneous vagus nerve stimulation, and their effects on intrarenal venous flow pattern in HFpEF. Frontiers in Neuroscience, 16. https://doi.org/10.3389/fnins.2022.999831
Baral, R., et al. (2024, July). Exercise training improves exercise capacity and quality of life in heart failure with preserved ejection fraction: A systematic review and meta-analysis of randomized controlled trials. European Heart Journal Open, 4(4). https://doi.org/10.1093/ehjopen/oeae033
Ho, J. E., & Robbins, J. M. (2022, April 1). Exercise training across the spectrum of HFpEF: Time for tailoring or one size fits all? JACC: Heart Failure. https://doi.org/10.1016/j.jchf.2022.02.003
Mueller, S., et al. (2021, February). Effect of high-intensity interval training, moderate continuous training, or guideline-based physical activity advice on peak oxygen consumption in patients with heart failure with preserved ejection fraction. JAMA, 325(6), 542. https://doi.org/10.1001/jama.2020.26812
Pandey, A., et al. (2021, September 14). Exercise intolerance in older adults with heart failure with preserved ejection fraction: JACC state-of-the-art review. Journal of the American College of Cardiology. https://doi.org/10.1016/j.jacc.2021.07.014
Kitzman, D. W., Brubaker, P. H., Morgan, T. M., Stewart, K. P., & Little, W. C. (2010, November). Exercise training in older patients with heart failure and preserved ejection fraction: A randomized, controlled, single-blind trial. Circulation: Heart Failure, 3(6), 659–667. https://doi.org/10.1161/CIRCHEARTFAILURE.110.958785
Mentz, R. J., et al. (2021, October). Rehabilitation intervention in older patients with acute heart failure with preserved versus reduced ejection fraction. JACC: Heart Failure, 9(10), 747–757. https://doi.org/10.1016/j.jchf.2021.05.007
Lee, V. Y. J., et al. (2024, February 1). The effect of weight loss through lifestyle interventions in patients with heart failure with preserved ejection fraction—A systematic review and meta-analysis of randomised controlled trials. Heart, Lung and Circulation. https://doi.org/10.1016/j.hlc.2023.11.022
Kitzman, D. W., et al. (2016, January). Effect of caloric restriction or aerobic exercise training on peak oxygen consumption and quality of life in obese older patients with heart failure with preserved ejection fraction: A randomized clinical trial. JAMA, 315(1), 36–46. https://doi.org/10.1001/jama.2015.17346
Obokata, M., Reddy, Y. N. V., Pislaru, S. V., Melenovsky, V., & Borlaug, B. A. (2017, July). Evidence supporting the existence of a distinct obese phenotype of heart failure with preserved ejection fraction. Circulation, 136(1), 6–19. https://doi.org/10.1161/CIRCULATIONAHA.116.026807
Billingsley, H. E., Carbone, S., Driggin, E., Kitzman, D. W., & Hummel, S. L. (2025, January). Dietary interventions in heart failure with preserved ejection fraction. JACC: Advances, 4(1), Article 101465. https://doi.org/10.1016/j.jacadv.2024.101465
Kamisaka, K., et al. (2021, December). Impact of weight loss in patients with heart failure with preserved ejection fraction: Results from the FLAGSHIP study. ESC Heart Failure, 8(6), 5293–5303. https://doi.org/10.1002/ehf2.13619
Jaarsma, T., et al. (2021, January). Self-care of heart failure patients: Practical management recommendations from the Heart Failure Association of the European Society of Cardiology. European Journal of Heart Failure, 23(1), 157–174. https://doi.org/10.1002/ejhf.2008
Son, Y. J., Choi, J., & Lee, H. J. (2020, September 2). Effectiveness of nurse-led heart failure self-care education on health outcomes of heart failure patients: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health. https://doi.org/10.3390/ijerph17186559
Athilingam, P., & Jenkins, B. (2018, January 1). Mobile phone apps to support heart failure self-care management: Integrative review. JMIR Cardio. https://doi.org/10.2196/10057
Inglis, S. C., Clark, R. A., Dierckx, R., Prieto-Merino, D., & Cleland, J. G. F. (2015, October). Structured telephone support or non-invasive telemonitoring for patients with heart failure. Cochrane Database of Systematic Reviews, 2015(10). https://doi.org/10.1002/14651858.CD007228.pub3
Sayers, S. L., Riegel, B., Pawlowski, S., Coyne, J. C., & Samaha, F. F. (2008, February). Social support and self-care of patients with heart failure. Annals of Behavioral Medicine, 35(1), 70–79. https://doi.org/10.1007/s12160-007-9003-x
Wilke, M. R., Broschmann, D., Sandek, A., Wachter, R., Edelmann, F., & Herrmann-Lingen, C. (2023, December). Longitudinal association between N-terminal B-type natriuretic peptide, anxiety and social support in patients with HFpEF: Results from the multicentre randomized controlled Aldo-DHF trial. BMC Cardiovascular Disorders, 23(1). https://doi.org/10.1186/s12872-023-03136-8
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Copyright (c) 2026 Anna-Maria Grzeczka, Katarzyna Pinkowska, Weronika Nawrocka, Zuzanna Korbel, Zuzanna Taciak, Mikołaj Jaszowski, Inez Michalska, Agnieszka Dąbrowska, Patrycja Pietraszkiewicz, Paula Żak, Filip Glista
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