From the Guidelines
The diagnosis of heart failure with preserved ejection fraction (HFpEF) should be based on a comprehensive evaluation that includes clinical symptoms, physical examination, laboratory tests, and imaging studies, with a preserved left ventricular ejection fraction (LVEF) of ≥50% and evidence of diastolic dysfunction or elevated filling pressures, as recommended by the 2022 AHA/ACC/HFSA guideline 1. The diagnosis of HFpEF requires a thorough assessment of the patient's symptoms, medical history, and physical examination, as well as laboratory tests and imaging studies to confirm the presence of heart failure and rule out other potential causes of symptoms.
- Key diagnostic tests include:
- Echocardiography to assess ejection fraction and diastolic function
- Natriuretic peptide levels (BNP or NT-proBNP) which are typically elevated
- Potentially cardiac catheterization to measure filling pressures directly
- Additional tests may include electrocardiogram, chest X-ray, and exercise testing with cardiopulmonary exercise testing to evaluate exercise capacity and hemodynamic response The H2FPEF score, which considers hypertension, age, BMI, pulmonary hypertension, atrial fibrillation, and E/e' ratio, and the HFA-PEFF algorithm are useful diagnostic frameworks to guide the diagnosis of HFpEF, as outlined in the 2022 AHA/ACC/HFSA guideline 1. Diagnosis can be challenging because symptoms overlap with other conditions and may require ruling out alternative causes of dyspnea such as pulmonary disease, anemia, or thyroid disorders.
- The European Society of Cardiology has developed a diagnostic algorithm that involves a pretest that assesses for HF symptoms and signs, typical clinical demographics, and diagnostic laboratory tests, ECG, and echocardiography 1. Early diagnosis is important as it allows for targeted management of underlying conditions and symptoms, potentially improving quality of life and outcomes.
- The writing committee proposes the addition of evidence of spontaneous or provokable increased LV filling pressures to the classifications of HFmrEF and HFpEF, as outlined in the 2022 AHA/ACC/HFSA guideline 1.
From the Research
Diagnosis of HFpEF
The diagnosis of Heart Failure with Preserved Ejection Fraction (HFpEF) is based on several key factors, including:
- Existence of symptoms and signs of heart failure 2
- Normal or approximately normal ejection fraction 2
- Diagnosing of left ventricular diastolic dysfunction by means of heart catheterization or Doppler echocardiography and/or elevated concentration of plasma natriuretic peptide 2
- Echocardiographic findings, such as isolated left ventricular diastolic dysfunction, left atrial dysfunction, and abnormal right ventricular-pulmonary artery coupling 3
- Detection of diastolic function abnormalities based on echocardiographic findings and abnormally elevated natriuretic peptide levels or invasive measurements of wedge pressure at rest or with exercise 4
Diagnostic Parameters
Several echocardiographic parameters have been identified as differentiating HFpEF from asymptomatic left ventricular diastolic dysfunction, including:
- Larger BMI 5
- Higher IVS thickness 5
- Larger LA diameter and volume index 5
- Higher E velocity and TR jet velocity 5
- Higher average E/e' ratio 5
- Lower lateral e' velocity, which is the best independent predictor of symptomatic state 5
Diagnostic Algorithms
There are currently two diagnostic algorithms for HFpEF: H2FPEF and HFA-PEFF, although there is limited data comparing their performance head to head in the same patient population 4