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A narrative review of heart failure with preserved ejection fraction in breast cancer survivors
  1. Vidhushei Yogeswaran1,
  2. Elena Wadden2,
  3. Warren Szewczyk3,
  4. Ana Barac4,
  5. Michael S Simon5,
  6. Charles Eaton6,
  7. Richard K Cheng1,
  8. Kerryn W Reding3
  1. 1 Division of Cardiology, University of Washington Medical Center, Seattle, Washington, USA
  2. 2 Division of Internal Medicine, University of Washington School of Medicine, Seattle, Washington, USA
  3. 3 Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington, USA
  4. 4 Department of Cardiology, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
  5. 5 Medical Oncology, Karmanos Cancer Center, Detroit, Michigan, USA
  6. 6 Family Medicine and Epidemiology Program, Brown University, Providence, Rhode Island, USA
  1. Correspondence to Dr Kerryn W Reding, University of Washington, Seattle, Washington, USA; kreding{at}


Advances in breast cancer (BC) treatment have contributed to improved survival, but BC survivors experience significant short-term and long-term cardiovascular mortality and morbidity, including an elevated risk of heart failure with preserved ejection fraction (HFpEF). Most research has focused on HF with reduced ejection fraction (HFrEF) after BC; however, recent studies suggest HFpEF is the more prevalent subtype after BC and is associated with substantial health burden. The increased HFpEF risk observed in BC survivors may be explained by treatment-related toxicity and by shared risk factors that heighten risk for both BC and HFpEF. Beyond risk factors with physiological impacts that drive HFpEF risk, such as hypertension and obesity, social determinants of health (SDOH) likely contribute to HFpEF risk after BC, impacting diagnosis, management and prognosis.

Increasing clinical awareness of HFpEF after BC and screening for cardiovascular (CV) risk factors, in particular hypertension, may be beneficial in this high-risk population. When BC survivors develop HFpEF, treatment focuses on initiating guideline-directed medical therapy and addressing underlying comorbidities with pharmacotherapy or behavioural intervention. HFpEF in BC survivors is understudied. Future directions should focus on improving HFpEF prevention and treatment by building a deeper understanding of HFpEF aetiology and elucidating contributing risk factors and their pathogenesis in HFpEF in BC survivors, in particular the association with different BC treatment modalities, including radiation therapy, chemotherapy, biological therapy and endocrine therapy, for example, aromatase inhibitors. In addition, characterising how SDOH intersect with these therapies is of paramount importance to develop future prevention and management strategies.

  • heart failure, diastolic
  • epidemiology

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  • Twitter @vidyogeswaran, @RichardKCheng2, @kerryn_reding

  • Contributors All authors contributed in meaningful ways to this work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests VY and RC are members of Heart’s Editorial Board.

  • Provenance and peer review Commissioned; externally peer reviewed.