What are the diagnostic criteria for Heart Failure with Preserved Ejection Fraction (HFpEF)?

From the Guidelines

Heart failure with preserved ejection fraction (HFpEF) is diagnosed when a patient has signs and symptoms of heart failure while maintaining a normal or near-normal left ventricular ejection fraction (typically ≥50%), as defined by the most recent guidelines 1. The diagnosis of HFpEF requires a comprehensive approach, considering clinical symptoms, signs of fluid overload, and objective evidence of preserved left ventricular systolic function on echocardiography. Key diagnostic criteria include:

• Clinical symptoms such as dyspnea, fatigue, and exercise intolerance
• Signs of fluid overload like peripheral edema or pulmonary congestion
• Objective evidence of preserved left ventricular systolic function on echocardiography, with an LVEF ≥50% 1
• Elevated natriuretic peptides (BNP >35 pg/mL or NT-proBNP >125 pg/mL) support the diagnosis, though levels may be lower than in heart failure with reduced ejection fraction
• Echocardiographic findings typically show left ventricular hypertrophy, left atrial enlargement, and evidence of impaired relaxation or increased filling pressures Invasive hemodynamic testing may be necessary in uncertain cases, with elevated left ventricular end-diastolic pressure (>16 mmHg) or pulmonary capillary wedge pressure (>12 mmHg at rest or >25 mmHg with exercise) confirming the diagnosis 1. Other causes of symptoms must be excluded, such as valvular heart disease, coronary artery disease, pulmonary disease, or anemia. The diagnosis is often challenging and requires integration of clinical, laboratory, and imaging findings.

Some of the key challenges in diagnosing HFpEF include determining the correct ejection fraction threshold, using the correct terminology, and differentiating HFpEF from other forms of heart failure, such as heart failure with mildly reduced ejection fraction (HFmrEF) 1. The most recent guidelines emphasize the importance of using a threshold of LVEF ≥50% to define HFpEF 1, and highlight the need for further research into the underlying characteristics, pathophysiology, and treatment of HFmrEF 1.

Overall, the diagnosis of HFpEF requires a careful and comprehensive approach, taking into account the latest guidelines and evidence-based recommendations 1.

From the Research

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

The diagnostic criteria for HFpEF include:

• Presence of typical heart failure symptoms and signs
• Preserved left ventricular ejection fraction (≥50%)
• Functional and/or structural left ventricular changes
• Objective evidence of cardiac structural and/or functional abnormalities
• Elevated natriuretic peptide levels 2, 3

Diagnostic Tools

Diagnostic tools for HFpEF include:

• Echocardiography (E/e')
• Biomarkers (NT-proBNP)
• Invasive stress testing, by means of right heart catheterisation at rest and during exercise
• Cardiac magnetic resonance imaging for accurate assessment of right ventricular function 4, 5

Challenges in Diagnosis

Challenges in diagnosing HFpEF include:

• Lack of a universal diagnostic algorithm and definition of HFpEF
• Limited diagnostic tools, such as natriuretic peptide levels and resting echocardiogram findings
• Overdiagnosis or underdiagnosis of HFpEF due to comorbidities that mimic HF 6, 3

Proposed Diagnostic Approach

A proposed diagnostic approach for HFpEF includes:

• A stepwise approach to diagnosis and treatment
• Establishment of a clinical diagnosis of HFpEF
• Referral for invasive diagnostic testing when necessary
• Current treatment approaches, including pharmacologic, nonpharmacologic, and risk factor modification interventions 6, 3