U.S. Guidelines for HFpEF Diagnosis and Treatment
The primary U.S. guidelines for heart failure with preserved ejection fraction (HFpEF) are the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure and the 2023 ACC Expert Consensus Decision Pathway on Management of HFpEF. 1, 2
Diagnostic Framework
Definition of HFpEF
HFpEF is defined as clinical heart failure with LVEF ≥50% that is not attributable to other causes such as infiltrative cardiomyopathy, hypertrophic cardiomyopathy, valvular disease, pericardial disease, or high-output heart failure 1.
Diagnostic Criteria
The diagnosis requires ALL of the following 2:
- Symptoms and/or signs of heart failure (dyspnea, exercise intolerance, edema)
- LVEF ≥50%
- Evidence of elevated filling pressures, demonstrated by at least one of:
- Elevated natriuretic peptides (NT-proBNP >125 pg/mL or BNP ≥35 pg/mL)
- Objective evidence of cardiogenic pulmonary or systemic congestion
Diagnostic Tools
The H2FPEF score is recommended to help discriminate HFpEF from noncardiac causes of dyspnea 2. This score (0-9 points) integrates:
- Obesity (2 points)
- Atrial fibrillation (3 points)
- Age >60 years (1 point)
- Treatment with ≥2 antihypertensive medications (1 point)
- Echocardiographic E/e' ratio >9 (1 point)
- Echocardiographic PA systolic pressure >35 mm Hg (1 point)
Interpretation:
- Score <2: Low likelihood of HFpEF
- Score 2-5: Intermediate probability—requires further evaluation with exercise echocardiogram or cardiac catheterization
- Score ≥6: High likelihood of HFpEF
Echocardiographic Assessment
Key structural and functional parameters to evaluate 2:
- Diastolic parameters (E/e' ≥15 suggests elevated filling pressures)
- Left atrial volume index (increased supports diagnosis)
- LV mass index (increased supports diagnosis)
- LV relative wall thickness
- Tricuspid regurgitation velocity
- LV global longitudinal systolic strain
When diagnosis remains uncertain after initial evaluation, exercise stress testing with echocardiographic evaluation of diastolic parameters or invasive hemodynamics at rest or with exercise should be performed 2.
Treatment Approach
Guideline-Directed Medical Therapy (GDMT)
The 2023 ACC Expert Consensus Decision Pathway emphasizes initiating GDMT in the ambulatory setting 1. The guidelines endorse the evidence-based approach from the 2022 AHA/ACC/HFSA guideline 1.
Key Treatment Principles
The guidelines emphasize 1:
- Shared decision-making between clinician and patient, particularly when clinical equipoise exists
- Multidisciplinary collaboration with pharmacists, cardiologists, HF specialists, endocrinologists, nephrologists, and palliative care specialists as needed
- Primary care clinicians should be able to initiate GDMT and recognize when cardiology referral is appropriate
- Focus is primarily on ambulatory management, though recommendations may be applied in acute inpatient settings
Role of Specialists
Primary Care Clinician:
- Maintain HFpEF in differential diagnosis for dyspnea, exercise intolerance, and edema
- Order relevant testing
- Initiate GDMT
- Recognize when cardiology referral is needed 1
Cardiology Specialist:
- Exclude alternative diagnoses
- Optimize GDMT
- Encourage clinical trial participation
- Identify indications for HF specialist referral 1
HF Specialist:
- Pursue advanced testing in diagnostic dilemmas
- Manage special or unusual cardiomyopathies
- Identify clinical trial eligibility
- Assess need for advanced therapies including heart transplantation 1
Important Caveats
HFpEF Mimics
Clinicians must exclude HFpEF mimics—conditions with LVEF ≥50% but primary noncardiac causes (kidney or liver disease) or specific cardiac causes (infiltrative cardiomyopathy, hypertrophic cardiomyopathy, valvular disease, pericardial disease, high-output HF) 1.
Evolving Evidence
The guidelines explicitly acknowledge that many questions remain unanswered in HFpEF care 1. Clinicians should:
- Incorporate relevant information published after these guidelines
- Not allow guidelines to supersede good clinical judgment
- Stay current with emerging trial data on additional agents and devices
NYHA Functional Classification
The guidelines use standard NYHA classification (I-IV) to stratify symptom severity and guide management decisions 1.