Is an ejection fraction (EF) of 60-65% considered a diagnosis of heart failure with preserved ejection fraction (HFpEF)?

Ejection Fraction of 60-65% and Heart Failure with Preserved Ejection Fraction

An ejection fraction (EF) of 60-65% meets the criteria for heart failure with preserved ejection fraction (HFpEF) if accompanied by heart failure symptoms, signs, and evidence of elevated filling pressures, but EF alone is not sufficient for diagnosis. 1, 2

Diagnostic Criteria for HFpEF

EF Threshold

• HFpEF is defined by an LVEF ≥50% according to the 2022 AHA/ACC/HFSA guidelines 1
• This threshold is consistent across multiple guidelines including the 2023 ACC Expert Consensus 1
• An EF of 60-65% falls well within this preserved range

Required Additional Criteria

Having an EF ≥50% alone is insufficient for HFpEF diagnosis. The following are also required:

1. Clinical symptoms and signs of heart failure:

   • Symptoms: Dyspnea, fatigue, exercise intolerance
   • Signs: Edema, rales, jugular venous distention

2. Evidence of cardiac structural/functional abnormalities:

   • Left atrial enlargement (left atrial volume index ≥34 mL/m²)
   • Left ventricular hypertrophy (LV mass index ≥95 g/m² for women or ≥115 g/m² for men)
   • Diastolic dysfunction (E/e' ratio ≥15)

3. Evidence of elevated filling pressures:

   • Elevated natriuretic peptides (BNP >35 pg/mL or NT-proBNP >125 pg/mL in ambulatory setting)
   • Elevated E/e' ratio ≥15
   • Elevated pulmonary artery pressures (tricuspid regurgitation velocity >2.8 m/s)

Diagnostic Algorithm for HFpEF

1. Step 1: Confirm LVEF ≥50% (your patient with 60-65% meets this criterion)
2. Step 2: Verify heart failure symptoms and signs
3. Step 3: Obtain objective evidence of:
   • Structural heart disease (left atrial enlargement, LV hypertrophy)
   • Elevated filling pressures (elevated natriuretic peptides or E/e' ratio)
4. Step 4: Rule out alternative diagnoses that could explain symptoms

Common Pitfalls in HFpEF Diagnosis

1. Relying solely on EF: An EF of 60-65% alone does not diagnose HFpEF without supporting evidence of heart failure symptoms and elevated filling pressures 1

2. Overlooking natriuretic peptide limitations: Natriuretic peptide levels may be lower in HFpEF than in HFrEF for the same degree of filling pressure elevation, particularly in obese patients 1, 2

3. Missing diastolic dysfunction: Single echocardiographic parameters have limited diagnostic accuracy; an integrated approach is necessary 1

4. Failing to consider HFpEF mimics: Conditions such as valvular disease, infiltrative disorders, or pericardial disease can present similarly 3

Special Considerations

• Obesity: May mask elevated natriuretic peptides despite HFpEF
• Atrial fibrillation: Common in HFpEF and may require different diagnostic thresholds
• Age: HFpEF is more common in older patients 4
• Gender: HFpEF is more common in women 4

Longitudinal Considerations

Interestingly, EF can change over time in HF patients. Research shows that in HFpEF patients, EF may decrease by approximately 5.8% over 5 years, with greater declines in older individuals and those with coronary disease 5. This suggests that progressive contractile dysfunction may contribute to HFpEF pathophysiology.

Conclusion

While an EF of 60-65% meets the preserved EF criterion for HFpEF, diagnosis requires the presence of heart failure symptoms/signs and evidence of elevated filling pressures. The diagnosis cannot be made based on EF alone, regardless of how well-preserved it is.