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

From the Guidelines

Diagnosing heart failure with preserved ejection fraction (HFpEF) requires a comprehensive approach that includes clinical evaluation, laboratory tests, imaging, and sometimes invasive hemodynamic assessment, with a focus on confirming preserved left ventricular ejection fraction (typically ≥50%) and demonstrating left ventricular hypertrophy, left atrial enlargement, and diastolic dysfunction, as recommended by the 2016 ESC guidelines 1. The diagnosis of HFpEF is more challenging than the diagnosis of heart failure with reduced ejection fraction (HFrEF) due to the absence of a single diagnostic test and the heterogeneous presentation of the disease.

Key Diagnostic Steps

• Evaluate symptoms such as dyspnea, fatigue, and fluid retention, along with risk factors including hypertension, diabetes, obesity, and advanced age.
• Perform physical examination to identify signs of fluid overload like jugular venous distention, peripheral edema, and pulmonary crackles.
• Conduct laboratory testing, including natriuretic peptides (BNP or NT-proBNP), which are typically elevated but may be lower than in HFrEF.
• Use echocardiography to confirm preserved left ventricular ejection fraction and demonstrate left ventricular hypertrophy, left atrial enlargement, and diastolic dysfunction, as outlined in the 2016 ASE/EACVI recommendations 1.
• Consider additional imaging like cardiac MRI to help identify specific etiologies.
• When diagnosis remains uncertain, utilize exercise stress testing with measurement of oxygen consumption or invasive hemodynamic assessment with right heart catheterization during rest and exercise to look for elevated left ventricular filling pressures.

Diagnostic Frameworks

• The H2FPEF score and HFA-PEFF algorithm are useful diagnostic frameworks that integrate multiple parameters to improve diagnostic accuracy.
• These frameworks can help in ruling out alternative causes of symptoms, as HFpEF can be challenging to definitively identify due to its heterogeneous presentation and the absence of a single diagnostic test. The 2016 ESC guidelines 1 and the 2016 ASE/EACVI recommendations 1 provide a comprehensive approach to diagnosing HFpEF, emphasizing the importance of an integrated assessment of multiple echocardiographic markers and clinical evaluation.

From the Research

Diagnosing Heart Failure with Preserved Ejection Fraction

To diagnose heart failure with preserved ejection fraction (HFpEF), several steps and considerations must be taken into account. The diagnosis of HFpEF is challenging due to its complex pathophysiology and the presence of multiple comorbidities in patients.

• Clinical Assessment: The initial step involves assessing heart failure symptoms and signs, as well as evaluating typical clinical demographics such as obesity, hypertension, diabetes mellitus, elderly age, and atrial fibrillation 2.
• Laboratory Tests and Echocardiography: Diagnostic laboratory tests, electrocardiogram, and echocardiography are crucial for identifying a normal left ventricular ejection fraction, ruling out significant heart valve disease or cardiac ischemia, and detecting at least one typical risk factor for HFpEF 2.
• Echocardiography and Natriuretic Peptide Score: Comprehensive echocardiography is performed to measure parameters such as mitral annular early diastolic velocity, LV filling pressure, left atrial volume index, LV mass index, and serum natriuretic peptide levels. A score is calculated based on these measures to determine the likelihood of HFpEF 2.
• Imaging Techniques: Imaging modalities like echocardiography and cardiac magnetic resonance (CMR) play a significant role in diagnosing HFpEF. Echocardiography is the primary imaging modality, while CMR can provide further characterization when needed 3, 4.
• Functional Testing: In cases of diagnostic uncertainty, functional testing such as echocardiographic or invasive hemodynamic exercise stress tests may be recommended 2.
• Establishing the Cause: Finally, establishing a possible specific cause of HFpEF or alternative explanations is essential for guiding treatment and management 2.

Key Considerations

• HFpEF is defined by the presence of heart failure signs and symptoms, identification of cardiac structural abnormalities leading to high left ventricular filling pressures, and an EF > 50% 3.
• Common imaging findings in HFpEF include left ventricular hypertrophy, diastolic dysfunction, left atrial enlargement, and elevated pulmonary artery pressure 3.
• Differentiating HFpEF from other causes of dyspnea may require advanced diagnostic methods, such as exercise echocardiography and invasive hemodynamics 5.
• A stepwise approach to the diagnosis and treatment of HFpEF, including clinical assessment, imaging, and functional testing, can improve accurate diagnosis and management of the disease 6.