On the search for the right definition of heart failure with preserved ejection fraction

Abstract

The definition of heart failure with preserved ejection fraction (HFpEF) has evolved from a clinically based "diagnosis of exclusion" to definitions focused on objective evidence of diastolic dysfunction and/ /or elevated left ventricular filling pressures. Despite advances in our understanding of HFpEF pathophysiology and the development of more sophisticated imaging modalities, the diagnosis of HFpEF remains challenging, especially in the chronic setting, given that symptoms are provoked by exertion and diagnostic evaluation is largely conducted at rest. Invasive hemodynamic study, and in particularinvasive exercise testing, is considered the reference method for HFpEF diagnosis. However, its use is limited as opposed to the high number of patients with suspected HFpEF. Thus, diagnostic criteria for HFpEF should be principally based on non-invasive measurements. As no single non-invasive variable can adequately corroborate or refute the diagnosis, different combinations of clinical, echocardiographic, and/or biochemical parameters have been introduced. Recent years have brought an abundance of HF-pEF definitions. Here, we present and compare four of them: 1) the 2016 European Society of Cardiology criteria for HFpEF; 2) the 2016 echocardiographic algorithm for diagnosing diastolic dysfunction; 3) the 2018 evidence-based H 2 FPEF score; and 4) the most recent, 2019 Heart Failure Association HFA-PEFF algorithm. These definitions vary in their approach to diagnosis, as well as sensitivity and specificity. Further studies to validate and compare the diagnostic accuracy of HFpEF definitions are warranted. Nevertheless, it seems that the best HFpEF definition would originate from a randomized clinical trial showing a favorable effect of an intervention on prognosis in HFpEF.

Characteristics and Treatment of Atrial Fibrillation with Respect to the Presence or Absence of Heart Failure. Insights from the Multicenter Polish Atrial Fibrillation (POL-AF) Registry

“…The diagnosis of HFpEF in patients with AF may be problematic because of the difficulty in separating symptoms that are due to HF from those due to AF [21]. Natriuretic peptides are elevated, and left atrial dilatation is common in AF regardless of concomitant HF [22,23]. This issue has been addressed in the recent consensus recommendation from the Heart Failure Association of the ESC, with higher cut-offs for HFpEF diagnosis for both left atrial volume index and natriuretic peptides in AF patients in the HFA-PEFF score [22].…”

Left atrial strain — a current clinical perspective

“…The importance of LA assessment is demonstrated by including its enlargement as one of the diagnostic criteria in the current HF definition [45]. In addition to its prognostic significance, LA volume is also used to assess LV diastolic function and the diagnosis of HF with preserved LV ejection fraction (HFpEF) [46,47]. However, LA function could be already abnormal even if LA size is preserved.…”

Do we need a definition of acute heart failure with preserved ejection fraction?

“…Concentrations of NPs may rise above the adopted “HF cut-points” in patients with no HF, but with other cardiac (AF, valvular heart disease) and extracardiac (pulmonary embolism, chronic obstructive pulmonary disease, liver disease, renal dysfunction) diseases, especially if they coexist, which is common in the elderly. Older age and lower body mass index are also associated with higher levels of NPs [ 6 , 18 , 19 ]. Thus, NPs cut-offs for HF adopted in the 2016 ESC guidelines are recommended for excluding, but not for confirming an HF diagnosis [ 6 ].…”

“…Thus, there is a need for separate diagnostic criteria for acute HFpEF. Most parameters included in algorithms for the diagnosis of chronic HFpEF or diastolic dysfunction, such as NPs, E/e’ ratio, mitral inflow velocities, tricuspid regurgitation velocity, and to a lesser extent left atrial volume index and e’ velocities, change with volume and pressure overload, as well as heart rate, and thus cut-offs used for chronic HFpEF may not be applicable in patients with acute symptoms [ 19 ].…”

“…In a patient with dyspnoea at rest or with minimal physical activity, normal LAP precludes left-sided cardiac origin of dyspnoea, including HFpEF. Concentrations of NPs correlate with LV filling pressures but have limitations presented above [ 6 , 18 , 19 ]. The presence of B-lines in lung ultrasound is an easily obtainable and reliable marker of pulmonary congestion, superior to chest X-ray, and proved its diagnostic and prognostic value both in hospitalised and ambulatory patients with HF, including HFpEF [ 22 ].…”