ESC Consensus on HFpEF Diagnosis: Key Points
Supriya Shore
The following are key points to remember from this consensus
statement on the diagnosis of heart failure with preserved ejection
fraction (HFpEF):
1. Although widely prevalent, diagnosis
of HFpEF remains challenging. A prior consensus statement on diagnosis
of HFpEF relied solely on echocardiographic data and natriuretic peptide
levels, both of which have a low sensitivity. Accordingly, a revised
algorithm has been proposed by the European Society of Cardiology (ESC),
which endorses a novel, stepwise diagnostic approach.
2. The proposed Heart Failure
Association algorithm (HFA–PEFF) consists of: Pretest Assessment (P),
Diagnostic workup with echocardiogram and natriuretic peptide score (E),
Advanced workup with functional testing in case of uncertainty (F), and
Final etiological workup (F).
3. Pretest assessment should be
performed in any patient who presents with symptoms and/or signs
compatible with HF. This includes a detailed clinical evaluation,
electrocardiogram, laboratory tests, and echocardiogram.
4. Echocardiogram is indicated in
all patients with HF symptoms. Preserved EF is defined as an EF >50%.
HFpEF is suggested by normal EF, nondilated left ventricle with
concentric remodeling, or left ventricular hypertrophy and left atrial
enlargement.
5. Step 2 includes a combination of
detailed echocardiographic measurements and natriuretic peptide levels.
To account for impact of modifiers such as age, etc., use of major and
minor diagnostic criteria are recommended. Recommended echocardiographic
criteria consist of functional markers (septal and lateral annular peak
early diastolic velocities, tricuspid regurgitation velocity) and
morphological markers (left atrial size and left ventricular mass
index). Natriuretic peptide cut-offs have been specified based on
underlying cardiac rhythm (sinus vs. atrial fibrillation).
6. For each major criterion met, 2
points are awarded, and 1 point is awarded for a minor criterion. A
score of ≥5 based on echocardiographic and natriuretic peptide levels is
diagnostic of HFpEF. A score of ≤1 makes a diagnosis of HFpEF very
unlikely.
7. For a score of 2-4 points,
additional workup in the form of diastolic stress echocardiography is
recommended. There is no consensus on which exercise protocol should be
used. If criteria for diastolic dysfunction during an exercise
echocardiogram through E/e’ ratio and tricuspid regurgitant velocity are
not met, invasive hemodynamic assessment through a right heart
catheterization at rest or at exercise is the next step. A rest
pulmonary capillary wedge pressure (PCWP) ≥15 mm Hg or exercise PCWP ≥25
mm Hg is diagnostic of HFpEF.
8. The final step consists of
establishing HFpEF etiology. This includes assessment of blood pressure
control, chronotropic competence, arrhythmias, and ischemia. Cardiac
magnetic resonance imaging should be considered where specific etiology
such as amyloidosis or hypertrophic cardiomyopathy are suspected.
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