How to diagnose heart failure with preserved ejection fraction: the HFA–PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Abstract

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the ‘HFA–PEFF diagnostic algorithm’. Step 1 (P=Pre‐test assessment) is typically performed in the ambulatory setting and includes assessment for heart failure symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non‐cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular (LV) ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e′), LV filling pressure estimated using E/e′, left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2–4 points) implies diagnostic uncertainty, in which case Step 3 (F1: Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2: Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

Multilayer myocardial strain improves the diagnosis of heart failure with preserved ejection fraction

“…Additionally, this performance is higher than of any other parameter included in our analysis, excepting only NT-proBNP that is borderline better with an AUC of 0.91(0.79-1), P < 0.001 ( Figure 1C). 9 In particular, a threshold value of Epi-GLS < À13.0% demonstrated an excellent diagnostic specificity (100%) for HFpEF. According to our data, a complementary threshold value for NT-proBNP > 203 ng/mL was able to detect all but two HFpEF patients, showing very good EpiGLS in the diagnostic of HFpEF sensitivity ( Figure 1D).…”

“…However, NT-proBNP exponentially increase in the restrictive phase of diastolic dysfunction; thus, it might be particularly inefficient in identifying HFpEF patients without or with an earlier stage of diastolic dysfunction. 9 Additionally, NT-proBNP is not efficient to separate HFpEF from HFrEF. 16 In contrast, we showed previously an excellent specificity for Endo-GCS, which is normal in HFpEF patients but significantly decreased in HFrEF, to separate HFpEF from HFrEF 8 with various degrees of severity.…”

“…Using commercially available software (Medis Suite, version 3.1 and QStrain RE version 2.0, Leiden, The Netherlands) we derived the values of myocardial strain at three distinct layers of the myocardium: subendocardial (Endo‐), mid‐myocardial (Myo‐), and subepicardial (Epi‐) for GLS and circumferential (GCS) strain as previously reported ( Figure ) 8 . To compare the diagnostic accuracy, we additionally assessed various others clinical, imaging, and biochemical parameters with a putative role in HFpEF diagnostic: LV end‐diastolic volume (LVEDV), LV mass (LVM), interventricular septum (IVS) wall thickness and free wall thickness, LA volume and strain, septal and lateral mitral annular early diastolic velocity (e`), E/e´ ratio, and plasma levels of N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) 9 . All the statistical analyses were performed with IBM SPSS v26 with the exception of comparative receiver operating characteristic analysis, which was performed with Medcalc v19.1.5, using the DeLong formula.…”

Therapeutic approaches in heart failure with preserved ejection fraction: past, present, and future

“…Patients with HFpEF are a heterogeneous group with numerous underlying aetiologies and pathophysiological abnormalities [7]. Thus, diagnosis of HFpEF can be challenging, as it rather describes a clinical syndrome than a single clinical diagnosis [8]. Also, there have been debates whether the definition of HFpEF should be based solely on LVEF, since LVEF-based HF subgroups may exhibit significantly overlapping phenotypes [9].…”

“…For instance, a composite HFpEF score determined by presence of atrial fibrillation, obesity, age > 60 years, treatment with ≥ 2 antihypertensives, echocardiographic E/e′ ratio > 9, and echocardiographic pulmonary artery systolic pressure > 35 mmHg has been shown to substantially identify patients at high risk of HFpEF that should undergo further evaluation [10]. According to the updated consensus recommendation by the Heart Failure Association (HFA) of the ESC [8], a step-wise diagnostic process should be applied in patients with suspected HFpEF. After an initial work-up based on clinical parameters and non-invasive tests (e.g.…”