Should You Document This as ADHF with Preserved Ejection Fraction?
Yes, you should document this as acute decompensated heart failure with preserved ejection fraction (ADHFpEF) if the patient meets the Universal Definition criteria: symptoms/signs of HF caused by structural/functional cardiac abnormalities PLUS either elevated natriuretic peptides (hospitalized: BNP >100 pg/mL or NT-proBNP >300 pg/mL) OR objective evidence of cardiogenic congestion, with an ejection fraction ≥50%. 1
Diagnostic Framework
The 2023 ACC Expert Consensus provides clear thresholds for making this diagnosis 1:
Required Elements (ALL must be present):
Symptoms and/or signs of HF - Use Framingham criteria as reference:
- Major criteria: orthopnea, jugular venous distension, hepatojugular reflux, rales, S3 gallop, acute pulmonary edema, cardiomegaly
- Minor criteria: dyspnea on exertion, nocturnal cough, ankle edema, tachycardia >120 bpm, hepatomegaly, pleural effusion
Structural/functional cardiac abnormality - Confirmed by echocardiogram
EF ≥50% 2
At least ONE of the following:
- Elevated natriuretic peptides (for hospitalized patients): BNP >100 pg/mL OR NT-proBNP >300 pg/mL 1
- Objective evidence of cardiogenic pulmonary or systemic congestion (imaging, invasive hemodynamics)
Critical Pitfalls in HFpEF Diagnosis
Be aware that natriuretic peptide levels are LOWER in HFpEF compared to HFrEF for the same degree of elevated left ventricular end-diastolic pressure 1. This is compounded by higher BMI being prevalent in HFpEF, which further suppresses natriuretic peptide levels. Therefore, use the lower hospitalized thresholds (BNP >100 pg/mL, NT-proBNP >300 pg/mL) rather than the higher thresholds used for HFrEF.
Recent evidence confirms that HFpEF and HFrEF present with comparable hemodynamic congestion despite lower BNP levels in HFpEF 3. Patients with acute HFpEF show similar venous congestion (enlarged IVC, atrial enlargement), RV dysfunction, and renal impairment as HFrEF patients, even with lower BNP.
When Diagnosis is Uncertain
If the clinical picture suggests HF but natriuretic peptides are borderline or normal:
- Obtain stress hemodynamics or exercise testing to provoke elevated LV filling pressures 2
- Use lung ultrasound to assess pulmonary congestion - this is particularly valuable in HFpEF where B-lines correlate with congestion even when BNP is relatively low 4
- Measure additional biomarkers: Mid-regional pro-ANP (MR-proANP) and soluble CD146 (sCD146) correlate better with echocardiographic markers of venous congestion in HFpEF than BNP 3
Documentation Considerations
Once you establish the diagnosis, document it as "Acute Decompensated Heart Failure with Preserved Ejection Fraction (ADHFpEF)" rather than just "ADHF" because:
- Treatment strategies differ between HFpEF and HFrEF 2
- Prognosis assessment requires EF classification 2
- Clinical trial eligibility depends on EF category 1
- The trajectory and management of HFpEF follows a relapsing-remitting pattern requiring specific follow-up strategies 5
Exclude Alternative Diagnoses First
Before finalizing the diagnosis, actively exclude cardiac and non-cardiac HF mimics 1:
- Pulmonary causes (COPD, pulmonary embolism, interstitial lung disease)
- Renal causes (volume overload from kidney disease)
- Hepatic causes (cirrhosis with ascites)
- Other cardiac conditions (constrictive pericarditis, restrictive cardiomyopathy, valvular disease)
The differential is particularly important in HFpEF because symptoms are nonspecific and overlap with multiple conditions, especially in older patients with multiple comorbidities 1, 5.
Prognostic Markers to Document
When documenting ADHFpEF, include these factors associated with adverse outcomes 6, 7, 8:
- Elevated serum creatinine (strong predictor of mortality)
- Elevated total leukocyte count
- Presence of shock
- Residual congestion at discharge (closely related to 30-day readmission)
- Low HDL-C (associated with adverse prognosis specifically in HFpEF)