What echocardiographic parameters are used to diagnose heart failure with preserved ejection fraction (HFpEF)?

Echocardiographic Parameters for Diagnosing HFpEF

The diagnosis of HFpEF on echocardiography requires LVEF ≥50% plus evidence of elevated LV filling pressures, best demonstrated by E/e′ ≥15 (or septal E/e′ >13 on exercise), left atrial volume index ≥34 mL/m², and tricuspid regurgitation velocity >2.8 m/sec. 1

Core Diagnostic Framework

The 2022 AHA/ACC/HFSA guidelines establish that HFpEF diagnosis requires two components 1:

• LVEF ≥50%
• Evidence of spontaneous or provokable increased LV filling pressures

Primary Echocardiographic Parameters

The most valuable parameters for identifying elevated filling pressures are 2, 1:

1. E/e′ Ratio

• E/e′ ≥15 strongly indicates elevated LV filling pressures
• Lateral E/e′ ≥12 has excellent diagnostic accuracy 3
• Exercise septal E/e′ >13 is highly predictive when resting studies are equivocal 4

2. Left Atrial Volume Index (LAVI)

• LAVI ≥34 mL/m² indicates chronic elevation of filling pressures 2, 3
• An enlarged LA clearly larger than the right atrium in apical four-chamber view strongly suggests chronically elevated pressures 2
• Caveat: Normal LAVI does not exclude HFpEF in early stages or acute presentations 2

3. Tricuspid Regurgitation Velocity

• TR velocity >2.8 m/sec supports elevated filling pressures 2
• Provides direct estimate of pulmonary artery systolic pressure when combined with right atrial pressure 2
• Exercise PA systolic pressure >35 mm Hg is incorporated into diagnostic scoring 1

Algorithmic Approach to Diastolic Assessment

Step 1: Initial Mitral Inflow Pattern

If E/A ≤0.8 with peak E ≤50 cm/sec:

• LAP is likely normal (Grade I diastolic dysfunction) 2

If E/A ≤0.8 with peak E >50 cm/sec, OR E/A 0.8-2.0:

• Proceed to Step 2 with additional parameters 2

Step 2: Apply Three-Parameter Rule

Evaluate these three parameters 2:

1. E/e′ ratio (elevated if ≥15)
2. LA maximum volume index (elevated if ≥34 mL/m²)
3. TR jet velocity (elevated if >2.8 m/sec)

Interpretation:

• ≥2 of 3 parameters elevated → LAP is elevated (Grade II diastolic dysfunction)
• Only 1 of 3 elevated → LAP is normal (Grade I diastolic dysfunction)
• Only 1 parameter available OR discrepancy between 2 parameters → Do not report LAP grade 2

Step 3: Consider Structural Heart Disease

Supporting findings that strengthen HFpEF diagnosis 2, 1:

• LV hypertrophy (LV mass exceeding gender-specific normal range)
• Regional wall motion abnormalities
• Exclude significant valvular disease, anemia, atrial arrhythmias that could cause LA enlargement 2

When Resting Echo Is Equivocal

Exercise stress echocardiography should be performed when diagnosis remains uncertain 1, 4:

The 2025 ESE score provides a validated approach 4:

• Resting LA reservoir strain <20% (2 points)
• Exercise septal E/e′ >13 (2 points)
• Increase in ultrasound B-lines (1 point)

Score interpretation:

• 0-1: Low probability (28%)
• 2-4: Intermediate probability (59-83%)
• 5: High probability (95-99%)

This ESE score demonstrated superior diagnostic accuracy (AUC 0.90) compared to standard ASE/EACVI criteria 4.

Additional Supportive Parameters

Lateral e′ velocity:

• Lateral e′ ≤8.2 cm/sec predicts symptomatic HFpEF with 76% sensitivity and 79% specificity 5
• Correlates inversely with NYHA class 5

Pulmonary vein flow:

• S/D ratio <1 supports elevated filling pressures when primary parameters are unavailable 2

Clinical Diagnostic Scores

H2FPEF Score integrates clinical and echo parameters 1:

• Obesity, atrial fibrillation, age >60 years
• ≥2 antihypertensive medications
• E/e′ >9
• PA systolic pressure >35 mm Hg

Scores ≥6 indicate high HFpEF likelihood; 2-5 require further testing; <2 suggests low probability 1.

Critical Pitfalls

1. Atrial fibrillation complicates interpretation of mitral inflow patterns—rely more heavily on structural parameters (LAVI, LV mass) and TR velocity 6

2. Athletes may have enlarged atria without elevated pressures—clinical context is essential 2

3. Single elevated parameter is insufficient—the three-parameter rule prevents overdiagnosis 2

4. Normal LAVI in acute presentations—consider exercise testing or invasive hemodynamics if clinical suspicion remains high 2, 1

5. Primary pulmonary disease must be excluded before attributing elevated TR velocity to HFpEF 2

The 2016 ASE/EACVI guidelines 2 provide the technical framework, while the 2022 AHA/ACC/HFSA guidelines 1 establish the diagnostic thresholds and integrate them into clinical algorithms. When resting echo is indeterminate, the 2025 ESE score 4 offers the most validated exercise-based approach.