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)

Abstract

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.

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Affiliated Institutions

• National Heart Centre Singapore SG
• Goethe University Frankfurt DE
• Brigham and Women's Hospital US
• Centre Hospitalier Universitaire de Rennes FR
• University of Milan IT
• Harvard University US
• University of Liège BE
• University of Cyprus CY
• National University of Singapore SG
• Charité - Universitätsmedizin Berlin DE
• University of Groningen NL
• Wroclaw Medical University PL
• Amsterdam University Medical Centers NL
• Boston University US
• University Medical Center Groningen NL
• Institute of Clinical and Experimental Medicine CZ
• Universitätsmedizin Göttingen DE
• Université de Rennes FR
• National University Heart Centre Singapore SG
• Inserm FR
• Utrecht University NL
• University Hospital of Zurich CH
• Berlin Institute of Health at Charité - Universitätsmedizin Berlin DE
• Sahlgrenska University Hospital SE
• IRCCS Policlinico San Donato IT
• University of Belgrade RS
• University Medical Center Utrecht NL
• University Hospital Frankfurt DE
• Cardiff University GB
• National and Kapodistrian University of Athens GR
• German Centre for Cardiovascular Research DE
• Laboratoire Traitement du Signal et de l'Image FR

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