The heart can fail even when it pumps normally

Science · Published 23 October 2026 Swipe more like this →

In short: Most people associate heart failure with a weakened muscle that can't pump blood effectively. However, a significant portion of patients suffer from HFpEF—a condition where the heart maintains a normal pumping percentage but struggles to fill properly. This distinction creates a complex diagnostic and treatment landscape.

Heart failure with preserved ejection fraction (HFpEF) accounts for approximately 40–50% of all heart failure diagnoses. Unlike traditional heart failure, where the heart's pumping ability is diminished, patients with HFpEF maintain a normal ejection fraction but experience difficulty in the heart's filling process. This condition is notably associated with older populations and high levels of multi-morbidity, leading to predictions that its prevalence will rise as global populations age. Research highlights that this condition is a primary driver of rising heart failure-related hospitalizations. It is frequently linked to the increasing incidence of various co-morbidities in elderly patients.

Despite its high prevalence, healthcare systems face significant hurdles in managing HFpEF. A 2017 survey revealed a stark disparity in service availability: 40% of heart failure services only managed patients with reduced ejection fraction (HFrEF). Historically, this was due to a lack of evidence for prognostic therapies specifically for HFpEF. The lack of locally commissioned services for HFpEF often stems from historical gaps in evidence regarding prognostic therapies. This creates a situation where many people cannot access specialist care pathways even when they could benefit from them.

Consequently, many patients are left in secondary care or returned to primary care without access to specialist pathways, potentially denying them guideline-based treatments and leading to unnecessary hospitalizations. Current efforts, such as those by NHS England, aim to standardize care through pathway support tools. These tools help align clinical practice with established guidelines, including the use of sodium-glucose co-transporter-2 (SGLT2) inhibitors for chronic heart failure. By streamlining these pathways, providers hope to reduce unwarranted variation in care and ensure that patients receive timely, accurate diagnoses regardless of their geographic location. Specific technology appraisals by NICE now sit within the heart failure pathway to guide treatment. These tools are designed to ensure equitable service provision across different healthcare providers.

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