What are the diagnosis criteria for chronic heart failure (CHF) with combined systolic and diastolic dysfunction?

From the Guidelines

Chronic heart failure (CHF) with combined systolic and diastolic dysfunction is diagnosed based on a combination of clinical signs and symptoms, elevated natriuretic peptide levels, and objective evidence of structural or functional alterations, including left ventricular ejection fraction (LVEF) and echocardiographic parameters.

Diagnosis Criteria

The diagnosis criteria for CHF with combined systolic and diastolic dysfunction include:

• Clinical signs and symptoms of heart failure, such as dyspnea and fatigue
• Elevated natriuretic peptide levels
• LVEF between 40% and 49% (HF with mid-range EF) or ≥50% (HF with preserved EF)
• Echocardiographic parameters, such as:
  • Left atrial volume index (LAVI)
  • Left ventricular mass index (LVMI)
  • Myocardial tissue velocity (e’, measured either at the septal and/or lateral mitral annulus)
  • The ratio of early mitral inflow E to e’ (E/e’)
  • Tricuspid regurgitation velocity (TRV)
• Objective evidence of structural or functional alterations, such as left atrial enlargement or increased LV mass

Classification of Heart Failure

According to the 2022 AHA/ACC/HFSA guideline 1, heart failure can be classified into three categories based on LVEF:

• HFrEF: LVEF ≤40%
• HFmrEF: LVEF between 40% and 49%
• HFpEF: LVEF ≥50%

Diagnostic Challenges

The diagnosis of HFmrEF and HFpEF can be challenging, as the clinical signs and symptoms of heart failure are frequently nonspecific and overlap with other clinical conditions 1. Elevated natriuretic peptide levels are supportive of the diagnosis, but normal levels do not exclude a diagnosis of HFmrEF or HFpEF.

Echocardiographic Parameters

Echocardiographic parameters, such as LAVI, LVMI, e’, E/e’, and TRV, can be used to support the diagnosis of HFmrEF and HFpEF 1. However, no single parameter can reliably diagnose HFpEF, and an integrated assessment of multiple echocardiographic markers is recommended.

Management

The management of patients with CHF with combined systolic and diastolic dysfunction is based on a set of therapeutic principles, including control of blood pressure, control of tachycardia, reduction in central blood volume, and alleviation of myocardial ischemia 1.

From the Research

Diagnosis Criteria for Chronic Heart Failure (CHF) with Combined Systolic and Diastolic Dysfunction

The diagnosis of CHF with combined systolic and diastolic dysfunction involves several conditions, including:

• Signs or symptoms of heart failure 2
• Evidence of systolic left ventricular (LV) dysfunction, characterized by a reduced left ventricular ejection fraction (LVEF) 3, 4
• Evidence of diastolic LV dysfunction, which can be obtained invasively (LV end-diastolic pressure >16 mmHg or mean pulmonary capillary wedge pressure >12 mmHg) or non-invasively by tissue Doppler (TD) (E/E' > 15) 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:
  • Tissue Doppler (TD) with an E/E' ratio > 15 2
  • 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 2, 4

Evaluation of Heart Failure

The initial evaluation of heart failure includes:

• History and physical examination 4
• Chest radiography 4
• Electrocardiography 4
• Laboratory assessment to identify causes or precipitating factors 4
• Echocardiography to confirm systolic or diastolic heart failure through assessment of left ventricular ejection fraction 4