ESC Consensus on HFpEF Diagnosis: Key Points

Pieske B, Tschöpe C, de Boer RA, et al.
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). Eur Heart J 2019;40:3297-3317.

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.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Echocardiography/Ultrasound, Magnetic Resonance Imaging

Keywords: Amyloidosis, Arrhythmias, Cardiac, Atrial Fibrillation, Biomarkers, Blood Pressure, Cardiac Catheterization, Cardiomyopathy, Hypertrophic, Diagnostic Imaging, Diastole, Echocardiography, Echocardiography, Stress, Electrocardiography, Heart Failure, Hypertrophy, Left Ventricular, Magnetic Resonance Imaging, Natriuretic Peptides, Pulmonary Wedge Pressure, Stroke Volume, Tricuspid Valve Insufficiency

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