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Eur Heart J. 2019 Oct 21;40(40):3297-3317. doi: 10.1093/eurheartj/ehz641.

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).

Author information

1
Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum.
2
German Center for Cardiovascular Research (DZHK), Berlin, Partner Site, Germany.
3
Department of Internal Medicine and Cardiology, German Heart Institute, Berlin, Germany.
4
Berlin Institute of Health (BIH), Germany.
5
Berlin Institute of Health (BIH) Center for Regenerative Therapies (BCRT), Charite, Berlin, Germany.
6
University Medical Centre Groningen, University of Groningen, Department of Cardiology, Groningen, the Netherlands.
7
School of Medicine, Cardiff University, Cardiff, UK.
8
Department of Cardiology and Pneumology, University Medicine Göttingen (UMG), Germany.
9
Cardiology and CIC, IT1414, CHU de Rennes LTSI, Université Rennes-1, INSERM 1099, Rennes, France.
10
Section of Cardiology, Department of Medicine, Sahlgrenska University Hosptal/Ostra, Göteborg, Sweden.
11
Department of Biomedical Sciences for Health, University of Milan, IRCCS, Milan, Italy.
12
Department of Cardiology, IRCCS Policlinico, San Donato Milanese, Milan, Italy.
13
National Heart Centre, Singapore & Duke-National University of Singapore.
14
University Medical Centre Groningen, The Netherlands.
15
Department of Cardiology, Heart Valve Clinic, University of Liège Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, Liège, Belgium.
16
Institute for Clinical and Experimental Medicine - IKEM, Prague, Czech Republic.
17
Institute for Experimental and Translational Cardiovascular Imaging, University Hospital Frankfurt.
18
German Centre for Cardiovascular Research (DZHK), Partner Site Frankfurt, Germany.
19
Medical University, Clinical Military Hospital, Wroclaw, Poland.
20
Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
21
Section of Preventive Medicine and Epidemiology and Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA.
22
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
23
University Heart Centre, University Hospital Zurich, Switzerland.
24
Department of Physiology and Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, The Netherlands.
25
University of Belgrade School of Medicine, Belgrade University Medical Center, Serbia.
26
Department of Cardiology, National and Kapodistrian University of Athens Medical School; University Hospital "Attikon", Athens, Greece.
27
University of Cyprus, School of Medicine, Nicosia, Cyprus.

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 HF 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 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'), left ventricular (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.

KEYWORDS:

HFpEF; Heart failure; biomarkers; diagnosis; echocardiography; exercise echocardiography; natriuretic peptides

PMID:
31504452
DOI:
10.1093/eurheartj/ehz641

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