What are the criteria to diagnose heart failure with a preserved ejection fraction (HFpEF)?

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

The diagnosis of HFpEF requires the presence of symptoms and/or signs of heart failure, a preserved ejection fraction (≥50%), elevated natriuretic peptides, and objective evidence of structural or functional cardiac abnormalities. 1

Core Diagnostic Components

1. Clinical Presentation

• Symptoms:
  • Dyspnea (especially on exertion)
  • Orthopnea
  • Nocturnal cough
  • Exercise intolerance
• Signs:
  • Bilateral edema
  • Jugular venous distension
  • Hepatojugular reflux
  • Rales
  • S3 gallop rhythm
  • Acute pulmonary edema

2. Ejection Fraction Assessment

• LVEF ≥50% on echocardiography or other cardiac imaging 1
• Patients with LVEF 40-49% are classified as HF with mildly reduced EF (HFmrEF), not HFpEF 1

3. Natriuretic Peptide Levels

• Ambulatory setting:
  • BNP >35 pg/mL (>50 pg/mL in atrial fibrillation)
  • NT-proBNP >125 pg/mL 1
• Hospitalized patients:
  • BNP >100 pg/mL
  • NT-proBNP >300 pg/mL 1
• Important caveat: Natriuretic peptide levels may be lower in HFpEF compared to HFrEF for similar elevations in filling pressures, especially in obesity 1

4. Structural and Functional Cardiac Abnormalities

At least one of the following echocardiographic parameters should be abnormal:

• Left atrial enlargement:
  • Left atrial volume index ≥34 mL/m² 1
• Left ventricular hypertrophy:
  • LV mass index ≥95 g/m² (women) or ≥115 g/m² (men) 1
• Diastolic dysfunction:
  • Average E/e' ratio ≥15 (strongly suggestive of elevated LV filling pressures) 1
  • Septal e' velocity <7 cm/s or lateral e' <10 cm/s 1
• Elevated pulmonary pressures:
  • Tricuspid regurgitation velocity >2.8 m/s (RVSP ≥35 mmHg) 1

Diagnostic Algorithm

Step 1: Initial Assessment

1. Evaluate symptoms and signs of heart failure
2. Check for typical risk factors (obesity, hypertension, diabetes, advanced age, atrial fibrillation)
3. Perform basic tests:
   • ECG
   • Natriuretic peptides
   • Basic laboratory tests
   • Chest radiography (may show cardiomegaly or pulmonary congestion) 1

Step 2: Echocardiographic and Natriuretic Peptide Evaluation

1. Confirm LVEF ≥50%
2. Rule out significant valvular disease
3. Assess for structural and functional abnormalities:
   • Left atrial volume index
   • LV mass index and relative wall thickness
   • E/e' ratio
   • Septal and lateral e' velocities
   • Tricuspid regurgitation velocity
   • LV global longitudinal strain (if available) 2

Step 3: Diagnostic Certainty Assessment

Based on the HFA-PEFF scoring system 2:

• Score ≥5 points: Definite HFpEF
• Score ≤1 point: HFpEF unlikely
• Score 2-4 points: Diagnostic uncertainty, proceed to functional testing

Step 4: Functional Testing (if diagnosis remains uncertain)

• Exercise echocardiography to assess for exercise-induced elevation in E/e' ratio
• Exercise hemodynamic assessment with right heart catheterization (gold standard)
• Consider cardiopulmonary exercise testing to quantify functional capacity and help identify the cause of dyspnea 1

Step 5: Exclude Alternative Diagnoses

• Rule out specific cardiac etiologies (infiltrative diseases, hypertrophic cardiomyopathy, constrictive pericarditis)
• Consider non-cardiac causes of symptoms (pulmonary disease, anemia, thyroid disorders)

Common Pitfalls and Caveats

1. Natriuretic peptide interpretation:

   • Normal levels do not exclude HFpEF, especially in obese patients 1
   • Values may be elevated due to other conditions (renal failure, atrial fibrillation, age)

2. Echocardiographic assessment:

   • Single parameters have limited diagnostic accuracy; an integrated approach is necessary 1
   • E/e' ratio alone has only modest correlation with invasive filling pressures (pooled r=0.56) 1

3. Diagnostic challenges in specific populations:

   • Obesity may mask elevated filling pressures and lower natriuretic peptide levels
   • Atrial fibrillation alters diastolic parameters and requires different cutoff values
   • Women have higher EFs and more preserved LV global longitudinal strain compared to men 1

4. "Unexplained" dyspnea on exertion:

   • Approximately 35% of HFpEF patients present without overt congestion at rest 3
   • These patients require exercise testing to demonstrate elevated filling pressures during exertion

By following this systematic approach, clinicians can more accurately diagnose HFpEF and distinguish it from other conditions that present with similar symptoms, allowing for appropriate management strategies to be implemented.