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

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

The diagnosis of HFpEF requires three mandatory components: (1) symptoms and/or signs of heart failure, (2) left ventricular ejection fraction ≥50%, and (3) evidence of elevated filling pressures demonstrated by either elevated natriuretic peptides OR objective evidence of cardiac structural/functional abnormalities. 1

Core Diagnostic Requirements

1. Clinical Presentation

You must document heart failure symptoms and/or signs using the Framingham criteria framework 1:

Major criteria (any of these strongly support HF):

• Orthopnea 1
• Jugular venous distension 1
• Hepatojugular reflux 1
• Rales 1
• S3 gallop rhythm 1
• Acute pulmonary edema 1
• Cardiomegaly 1

Minor criteria (supportive findings):

• Dyspnea on exertion 1
• Nocturnal cough 1
• Ankle edema 1
• Tachycardia >120 bpm 1
• Hepatomegaly 1
• Pleural effusion 1

2. Ejection Fraction Threshold

LVEF must be ≥50% on echocardiography 1. Patients with LVEF 41-49% are classified as HFmrEF (mildly reduced), not HFpEF 1. This 50% cutoff is based on consensus from the U.S. Heart Failure Collaboratory and the Universal Definition of Heart Failure 1.

3. Evidence of Elevated Filling Pressures

You must demonstrate elevated filling pressures through at least one of the following 1:

A. Natriuretic Peptide Elevation

Ambulatory/outpatient thresholds:

• BNP >35 pg/mL 1, 2
• NT-proBNP >125 pg/mL 1, 2

Hospitalized/acute thresholds:

• BNP >100 pg/mL 1, 2
• NT-proBNP >300 pg/mL 1, 2

Critical caveat: Natriuretic peptide levels in HFpEF are typically lower than in HFrEF for the same degree of elevated filling pressure 1. Obesity significantly reduces natriuretic peptide levels despite elevated filling pressures 2, 3. A normal BNP does not exclude HFpEF, particularly in obese patients 2.

B. Echocardiographic Evidence of Structural/Functional Abnormalities

Key structural parameters (any of these support diagnosis) 1, 4:

• Left atrial volume index (LAVI) elevation 1, 4
• LV mass index (LVMI) elevation indicating LV hypertrophy 1, 4
• E/e′ ratio ≥15 (indicates high filling pressures) 1, 4
• Tricuspid regurgitation velocity elevation 4
• Pulmonary artery systolic pressure >35 mm Hg 1

Important: No single echocardiographic parameter reliably diagnoses HFpEF; you must integrate multiple markers 4. E/e′ between 8-15 is indeterminate and requires additional assessment 4.

C. Invasive Hemodynamic Confirmation

When diagnosis remains uncertain after noninvasive testing, invasive hemodynamics at rest or with exercise can confirm elevated LV filling pressures (pulmonary capillary wedge pressure or LV end-diastolic pressure) 1, 2.

Diagnostic Algorithm Approach

Step 1: Initial Assessment

• Evaluate for HF symptoms/signs and typical risk factors (hypertension, obesity, diabetes, age >60, atrial fibrillation) 1, 2
• Obtain ECG (may show LV hypertrophy, atrial fibrillation, repolarization abnormalities) 1, 2
• Measure natriuretic peptides 1, 2
• Perform echocardiography to confirm LVEF ≥50% 1

If all elements are normal, HFpEF is highly unlikely 1.

Step 2: Comprehensive Echocardiographic Assessment

Assess for structural and functional abnormalities including LAVI, LVMI, E/e′ ratio, and pulmonary pressures 1, 4. The European Society of Cardiology requires satisfying multiple echocardiographic parameters, not just one 4.

Step 3: Advanced Testing When Diagnosis Uncertain

If initial assessment is indeterminate (e.g., E/e′ 8-15, intermediate natriuretic peptides), proceed with 1, 2:

• Exercise stress echocardiography with diastolic parameter evaluation 1, 2
• Invasive hemodynamic exercise testing 1, 2
• Cardiac MRI to evaluate for infiltrative disease, fibrosis, or pericardial abnormalities 2

Step 4: Exclude HFpEF Mimics

You must rule out alternative diagnoses 2:

Noncardiac causes:

• Kidney failure 2
• Liver failure 2
• Chronic venous insufficiency 2

Cardiac mimics with preserved EF:

• Infiltrative/restrictive cardiomyopathies (especially cardiac amyloidosis) 2
• Hypertrophic cardiomyopathy 2
• Valvular heart disease 2
• Pericardial disease (constrictive pericarditis) 2
• High-output heart failure 2

Clinical Scoring Systems

H2FPEF Score

When diagnosis is uncertain, the H2FPEF score integrates six variables 1:

• Heavy (obesity/BMI >30): 2 points
• Hypertension (≥2 antihypertensive medications): 1 point
• Atrial Fibrillation (paroxysmal or persistent): 3 points
• Pulmonary hypertension (echo PA systolic pressure >35 mm Hg): 1 point
• Elder (age >60 years): 1 point
• Filling pressure (E/e′ >9): 1 point

Score interpretation 1:

• 0-1 points: Low probability of HFpEF
• 2-5 points: Intermediate (requires further testing)
• 6-9 points: High probability of HFpEF

Critical Pitfalls to Avoid

Do not diagnose HFpEF based solely on:

• Dyspnea and preserved EF without confirming elevated filling pressures 2
• A single elevated natriuretic peptide without clinical context 1
• Diastolic dysfunction on echo without HF symptoms 2

Remember:

• Normal natriuretic peptides do not exclude HFpEF, especially in obesity (BMI >35) 2, 3
• Not all patients with dyspnea, preserved EF, and comorbidities have HFpEF 2
• HFpEF is often a diagnosis of exclusion after ruling out specific cardiac and noncardiac causes 2
• Testing should be guided by clinical suspicion; not every patient requires exhaustive evaluation for all possible mimics 2
• A normal ECG combined with BNP <35 pg/mL makes HFpEF highly unlikely 1