What are the diagnosis criteria for Heart Failure with preserved Ejection Fraction (Hfpef)?

From the Guidelines

Heart failure with preserved ejection fraction (HFpEF) is diagnosed based on three key criteria: symptoms and signs of heart failure, a preserved left ventricular ejection fraction of 50% or greater, and evidence of diastolic dysfunction or elevated filling pressures, as supported by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.

Diagnosis Criteria

The diagnosis of HFpEF requires a comprehensive approach, including:

• Symptoms and signs of heart failure, such as shortness of breath, fatigue, and fluid retention
• A preserved left ventricular ejection fraction, typically defined as 50% or greater, as stated in the 2022 AHA/ACC/HFSA guideline 1
• Evidence of diastolic dysfunction or elevated filling pressures, which can be determined through:
  • Echocardiography
  • Invasive hemodynamic measurements
  • Elevated natriuretic peptide levels (BNP >35 pg/mL or NT-proBNP >125 pg/mL)

Supporting Criteria

Additional supporting criteria for HFpEF diagnosis include:

• Left ventricular hypertrophy
• Left atrial enlargement
• Elevated pulmonary artery pressures
• Common comorbidities that increase suspicion for HFpEF, such as:
  • Hypertension
  • Obesity
  • Diabetes
  • Atrial fibrillation

Diagnostic Tools

The H2FPEF score and HFA-PEFF algorithm are useful diagnostic tools that incorporate these criteria to help clinicians make a more accurate diagnosis, as mentioned in the 2022 AHA/ACC/HFSA guideline 1.

Importance of Early Diagnosis

Early diagnosis of HFpEF is crucial, as management focuses on treating underlying conditions and symptoms, and specific HFpEF therapies like SGLT2 inhibitors have shown benefit in recent trials, highlighting the importance of accurate diagnosis and treatment, as supported by the 2022 AHA/ACC/HFSA guideline 1.

From the Research

Diagnosis Criteria for Heart Failure with Preserved Ejection Fraction (HFpEF)

The diagnosis of HFpEF is challenging and requires a comprehensive approach. According to 2, the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) recommends a stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. The key steps in this algorithm include:

• Step 1: Pre-test assessment, which involves evaluating HF symptoms and signs, clinical demographics, and diagnostic laboratory tests
• Step 2: Echocardiography and Natriuretic Peptide Score, which requires comprehensive echocardiography and measures various parameters, including mitral annular early diastolic velocity and left ventricular filling pressure
• Step 3: Functional testing, which involves echocardiographic or invasive haemodynamic exercise stress tests in cases of diagnostic uncertainty
• Step 4: Final aetiology, which aims to establish a possible specific cause of HFpEF or alternative explanations

Key Diagnostic Parameters

Some of the key diagnostic parameters for HFpEF include:

• Left ventricular ejection fraction (LVEF) ≥50% 3, 4
• Elevated natriuretic peptide levels, although normal levels do not exclude a diagnosis of HFpEF 2
• Presence of symptoms with or without signs of HF 4
• Objective evidence of cardiac structural and/or functional abnormalities 4
• Typical risk factors, such as obesity, hypertension, diabetes mellitus, elderly, and atrial fibrillation 2

Challenges in Diagnosis

The diagnosis of HFpEF remains challenging due to:

• Lack of clear consensus on how HFpEF should be defined 4
• Limitations of diagnostic tools, such as natriuretic peptide levels and resting echocardiogram findings 4
• Overdiagnosis or underdiagnosis of HFpEF in certain cases 4
• Need for further research to improve classification and diagnosis of HFpEF 2