Does mild pulmonary hypertension qualify a person for a diagnosis of Heart Failure with Preserved Ejection Fraction (HFPEF)?

Pulmonary Hypertension and HFpEF Diagnosis

Mild pulmonary hypertension alone is not sufficient to diagnose Heart Failure with Preserved Ejection Fraction (HFpEF), but it is an important component of the diagnostic criteria and risk assessment tools.

Diagnostic Criteria for HFpEF

According to the 2022 AHA/ACC/HFSA guidelines, the diagnosis of HFpEF requires three essential components:

1. Presence of signs and/or symptoms of chronic heart failure
2. LVEF ≥50%
3. Evidence of increased left ventricular filling pressures at rest, exercise, or other provocations 1

The third criterion can be fulfilled through:

• Elevated natriuretic peptide levels
• Echocardiographic diastolic parameters (e.g., E/e' ≥15)
• Invasive hemodynamic measurements showing elevated filling pressures
• Evidence of structural heart disease (increased left atrial size/volume or increased LV mass)

Role of Pulmonary Hypertension in HFpEF Diagnosis

Pulmonary hypertension (PH) is frequently associated with HFpEF but is not independently diagnostic. Its significance includes:

• PH serves as a marker of disease severity and progression in HFpEF 2, 3
• Pulmonary artery systolic pressure >35 mmHg is one component of the H2FPEF diagnostic score 1
• PH in HFpEF is associated with:
  • Worse symptoms
  • Greater exercise intolerance
  • More frequent hospitalizations
  • Reduced survival 2, 4

H2FPEF Diagnostic Score

The H2FPEF score is a validated clinical tool that incorporates pulmonary hypertension as one of six variables:

1. Obesity
2. Atrial fibrillation
3. Age >60 years
4. Treatment with ≥2 antihypertensive medications
5. E/e' ratio >9
6. Pulmonary artery systolic pressure >35 mmHg

This score ranges from 0-9, with scores ≥6 indicating high likelihood of HFpEF 1.

Types of PH in HFpEF

PH in HFpEF can be categorized as:

1. Isolated postcapillary PH (IpcPH): Elevated left-sided filling pressures without significant pulmonary vascular remodeling
2. Combined postcapillary and precapillary PH (CpcPH): Includes pulmonary vascular remodeling with elevated pulmonary vascular resistance (≥3 Wood units) 3, 4

CpcPH represents a more severe phenotype with worse outcomes 5.

Clinical Implications

• Mild PH alone is insufficient for HFpEF diagnosis but contributes to risk stratification
• The presence of PH in patients with preserved EF should prompt evaluation for other HFpEF criteria
• Mortality in PH-HFpEF is substantial (23.6% at 1 year, 48.2% at 5 years) 5
• Hemodynamic parameters like transpulmonary gradient, pulmonary vascular resistance, and diastolic pulmonary gradient are all associated with mortality and cardiac hospitalizations in HFpEF 5

Diagnostic Algorithm

When evaluating a patient with mild pulmonary hypertension:

1. Confirm LVEF ≥50%

2. Assess for signs/symptoms of heart failure

3. Evaluate for evidence of increased LV filling pressures:

   • Elevated natriuretic peptides (BNP ≥35 pg/mL or NT-proBNP >125 pg/mL)
   • Echocardiographic evidence of diastolic dysfunction (E/e' ≥15)
   • Consider exercise stress testing with echocardiography if diagnosis remains uncertain
   • Consider invasive hemodynamic assessment if non-invasive testing is inconclusive

4. Calculate H2FPEF score to determine likelihood of HFpEF

Conclusion

While mild pulmonary hypertension contributes to the diagnostic assessment of HFpEF, it must be considered alongside other clinical, laboratory, and imaging findings to establish the diagnosis according to current guidelines.