Is an ischemic workup recommended in patients with new heart failure with preserved ejection fraction (HFpEF)?

Ischemic Workup in New HFpEF

Yes, an ischemic workup is recommended for all patients with newly diagnosed heart failure with preserved ejection fraction (HFpEF), as coronary artery disease (CAD) is a common underlying cause that requires specific treatment. 1

Rationale for Ischemic Evaluation in HFpEF

Coronary artery disease evaluation is essential in HFpEF for several reasons:

• All patients with HFpEF should be systematically evaluated for coronary artery disease 2
• Myocardial ischemia due to coronary microvascular dysfunction may be a key pathophysiological mechanism in many HFpEF cases 3
• Identifying ischemic etiology can significantly alter treatment approach and improve outcomes
• Coronary disease is often underdiagnosed in HFpEF patients despite being a potentially treatable cause

Recommended Diagnostic Approach

Initial Assessment

• Evaluate clinical risk factors for CAD
• Assess for symptoms of angina (noting that many HFpEF patients may have atypical presentations)
• Consider baseline ECG abnormalities

Non-invasive Testing Options (in order of preference)

1. Coronary CTA:

   • Excellent first-line test with high sensitivity and negative predictive value
   • CT coronary calcium score = 0 can effectively exclude CAD 1
   • If calcium score >0, proceed with full coronary CTA

2. Stress Testing with Imaging:

   • Stress echocardiography to identify wall motion abnormalities 1
   • Stress SPECT/CT or PET/CT for myocardial perfusion assessment
   • Consider stress MRI with late gadolinium enhancement (LGE) in appropriate candidates

3. Cardiac MRI with LGE:

   • Helpful for tissue characterization and identifying ischemic patterns 1
   • Can detect both macro and microvascular coronary disease

When to Consider Invasive Coronary Angiography

• High pretest probability of CAD or typical angina symptoms
• Abnormal non-invasive testing suggesting ischemia
• When planning potential revascularization

Common Pitfalls to Avoid

1. Assuming HFpEF is solely due to hypertension or diastolic dysfunction

   • Emerging evidence shows that microvascular coronary dysfunction may be a primary mechanism in many HFpEF cases 3

2. Overlooking coronary microvascular dysfunction

   • Standard coronary angiography may miss microvascular disease
   • Consider additional functional testing when epicardial vessels appear normal

3. Relying solely on symptoms

   • Many HFpEF patients have atypical or absent angina despite significant CAD
   • Objective testing is necessary regardless of symptom status

4. Stopping at diagnosis without treatment planning

   • The purpose of ischemic workup is to guide specific therapy
   • Revascularization may significantly improve outcomes in appropriate candidates

Clinical Implications

Identifying CAD in HFpEF patients has important therapeutic implications:

• Allows for targeted anti-ischemic therapies
• May identify candidates for revascularization
• Guides secondary prevention strategies
• Helps differentiate between various HFpEF phenotypes for more personalized treatment 4

The evidence strongly supports routine ischemic evaluation in all patients with newly diagnosed HFpEF to improve diagnosis, guide treatment, and potentially improve outcomes.