From the Guidelines
Diastolic heart failure, also known as heart failure with preserved ejection fraction (HFpEF), is diagnosed when a patient has signs and symptoms of heart failure with a normal or near-normal left ventricular ejection fraction (typically ≥50%) and evidence of increased LV filling pressures at rest, exercise, or other provocations, as stated in the 2022 AHA/ACC/HFSA guideline 1. The key diagnostic criteria include clinical symptoms of heart failure (such as dyspnea, fatigue, and fluid retention), evidence of normal systolic function, and demonstration of abnormal left ventricular relaxation, filling, or diastolic stiffness. Specific diagnostic findings include:
- Elevated natriuretic peptides
- Echocardiographic evidence of diastolic dysfunction (such as an E/e' ≥ 15)
- Structural heart changes like left ventricular hypertrophy, increased left atrial size and volume (left atrial volume index) and/or an increase in LV mass (LV mass index) 1. Additional supporting criteria include elevated pulmonary artery pressures, abnormal global longitudinal strain with preserved ejection fraction, and reduced exercise capacity with increased filling pressures during exertion. The diagnosis of HFpEF can be facilitated by using a clinical composite score, such as the H2 FPEF score, which integrates predictive variables like obesity, atrial fibrillation, age, treatment with antihypertensive medications, echocardiographic E/e' ratio, and echocardiographic PA systolic pressure 1. Exercise stress testing with echocardiographic evaluation of diastolic parameters or invasive hemodynamics at rest or with exercise can also be helpful in establishing the diagnosis 1. It is essential to note that the European Society of Cardiology has developed a diagnostic algorithm that involves a pretest assessment and assigns points for functional, morphological, and biomarker domains 1. However, the 2022 AHA/ACC/HFSA guideline provides the most recent and highest-quality evidence for diagnosing HFpEF, and its criteria should be prioritized in clinical practice 1.
From the Research
Diagnostic Criteria for Diastolic Heart Failure
The diagnosis of diastolic heart failure, also known as heart failure with preserved ejection fraction (HFpEF), requires the presence of certain conditions, including:
- Signs or symptoms of heart failure
- Normal or mildly abnormal systolic left ventricular (LV) function, defined as an LV ejection fraction (LVEF) > 50% and an LV end-diastolic volume index (LVEDVI) < 97 mL/m(2) 2
- Evidence of diastolic LV dysfunction, which can be obtained invasively or non-invasively using techniques such as tissue Doppler (TD) or blood flow Doppler of mitral valve or pulmonary veins 2
Diagnostic Evidence of Diastolic LV Dysfunction
Diagnostic evidence of diastolic LV dysfunction can be obtained through:
- Invasive measurements, such as LV end-diastolic pressure > 16 mmHg or mean pulmonary capillary wedge pressure > 12 mmHg 2
- Non-invasive measurements, such as TD (E/E' > 15) or blood flow Doppler of mitral valve or pulmonary veins 2
- Echo measures of LV mass index or left atrial volume index 2
- Electrocardiographic evidence of atrial fibrillation 2
- Plasma levels of natriuretic peptides, such as NT-pro BNP 3
Clinical Characteristics of Diastolic Heart Failure
Diastolic heart failure is characterized by:
- Preserved LVEF (> 50%) 4, 5
- Signs and symptoms of heart failure, such as breathlessness and fatigue 4, 5
- Increased incidence with age, with approximately 50% of older patients with heart failure having isolated diastolic dysfunction 5
- Lower annual mortality rate compared to heart failure with systolic dysfunction, but substantial morbidity rate 6