How to Diagnose Heart Failure with Preserved Ejection Fraction (HFpEF)
Practical, step-by-step criteria to diagnose HFpEF: clinical clues, echocardiography, natriuretic peptides, scoring tools (H2FPEF), and when to order advanced hemodynamics.
What is HFpEF?
HFpEF is heart failure due to impaired diastolic relaxation and increased LV stiffness, leading to elevated filling pressures despite preserved systolic function.
- Symptoms/signs of heart failure plus LVEF ≥ 50%.
- Objective evidence of diastolic dysfunction or elevated LV filling pressures.
Clinical Presentation
- Dyspnea on exertion, orthopnea, PND, fatigue, exercise intolerance.
- Peripheral edema, raised JVP, bibasal crepitations, S4.
- Common comorbidities: long-standing hypertension, diabetes, AF, obesity, CKD; often older women.
HFpEF symptoms frequently mimic COPD, obesity/deconditioning, or anemia—use objective testing to avoid misdiagnosis.
Step 1: Initial Clinical Assessment
History
Document risk factors, onset/worsening of dyspnea, orthopnea/PND, exercise capacity, and prior cardiac disease.
Examination
Look for edema, rales, raised JVP, S4, hepatomegaly; check BP, BMI/waist (obesity common).
Step 2: Echocardiographic Evaluation
- LVEF ≥ 50% with normal LV size; concentric remodeling or LVH common.
- Left atrial enlargement (LA volume index > 34 mL/m²).
- Diastolic indices: septal e′ < 7 cm/s or lateral e′ < 10 cm/s; average E/e′ > 14.
- Tricuspid regurgitation jet velocity > 2.8 m/s suggests pulmonary pressures elevation.
If resting parameters are borderline, exercise or diastolic-stress echo may unmask elevated filling pressures.
Step 3: Biomarkers & Laboratory Support
- BNP > 35 pg/mL or NT-proBNP > 125 pg/mL supports heart failure (higher cut-offs in AF or renal dysfunction).
- Basic labs to assess contributors: FBC (anemia), TSH, renal panel/electrolytes, HbA1c, ferritin, lipids.
Normal natriuretic peptides do not fully exclude HFpEF, especially in obese patients.
Step 4: Scoring Systems
| Parameter | Points |
|---|---|
| Heavy (BMI > 30 kg/m²) | 2 |
| Hypertensive (≥2 antihypertensive drugs) | 1 |
| Atrial Fibrillation | 3 |
| Pulmonary artery systolic pressure > 35 mmHg | 1 |
| Elder (Age > 60 years) | 1 |
| E/e′ > 9 | 1 |
Interpretation: 0–1 low, 2–5 intermediate, 6–9 high probability of HFpEF.
Step 5: Advanced/Confirmatory Testing
- Right heart catheterization with exercise when non-invasive tests are inconclusive; HFpEF supported if PAWP/LVEDP > 15 mmHg at rest or > 25 mmHg during exercise.
- Cardiac MRI to assess fibrosis, amyloidosis, hypertrophic or infiltrative disease.
- Cardiopulmonary exercise testing for unexplained exertional dyspnea and objective capacity.
Step 6: Exclude Important Mimics
- COPD or primary pulmonary hypertension.
- Severe obesity/deconditioning; obstructive sleep apnea.
- Anemia, thyroid disease, chronic kidney disease.
- Pericardial constriction/tamponade, significant valvular disease.
- Ischemia causing transient diastolic dysfunction.
Key Diagnostic Checklist
| Feature | Required Finding |
|---|---|
| Symptoms/signs of HF | Present |
| Left Ventricular Ejection Fraction | ≥ 50% |
| Diastolic dysfunction / elevated filling pressure | e′ low, E/e′ > 14, LA volume index > 34 mL/m² |
| Natriuretic peptides | BNP/NT-proBNP elevated (context-specific cut-offs) |
| Exclusion of mimics | Clinical + tests to rule out non-cardiac/valvular causes |
Diagnosis is integrative: align clinical picture with echo, labs, and—when needed—hemodynamics.
