What is HFpEF & How do we make the diagnosis? Barry Borlaug MD, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
Introduction Review of Heart Failure with Preserved Ejection Fraction: • Definition of HFpEF • Diagnostic approaches HFpEF
What is HFpEF? How do we make the diagnosis? • Inability of the heart to pump blood adequately at normal filling pressures in pt w EF≥50% • Clinical diagnosis relies on finding objective evidence: • High filling pressures • JVD, S3, rales, Kerley B lines, etc • ↑NT proBNP , E/e’, LAVI, PASP • Cath • Inadequate output • CPXT • Cath • Exclude other etiologies that we treat differently
How to Diagnose HFpEF: 2016 ESC Guidelines Mayo Data: Sensitivity 60%!! Obokata…Borlaug Circulation 2017 LAE, LVH, E/e’>13 + e’<9 Ponikowski Eur Heart J 2016
70 yo woman with DOE • EF = 60%, h/o HTN, metabolic syndrome • NYHA II-III dyspnea and fatigue • No clear episodes of volume overload • Appears “Euvolemic”, normal BNP • Echo: – Mild LAE – E/A 1.1, E/e’ 11, RVSP 32 ESC algorithm says “no HFpEF ”
Referred for invasive hemodynamic assessment 40 Watts Exercise 180 160 140 120 100 80 60 40 20 0 PCWP=LVEDP=12 mmHg; PCWP=LVEDP=40 mmHg; CO 5.7 l/min CO 7.8 l/min
Dx: HFpEF
58% of pts with normal exam, echo, BNP & resting hemos have HF by exercise
Normal NT-proBNP does NOT exclude HFpEF 50 % of HFpEF patients 40 30 20 10 0 <125 <200 <300 NT-proBNP cutoff used (pg/ml) Obokata, Borlaug Circulation 2017
E/e’ ratio: Useful when High Only p<0.0001 60 r= 0.63 NCD HFpEF 50 p<0.0001 50 E/e’ medial 40 E/e’ medial 40 30 30 20 20 10 10 0 0 0 5 10 15 20 25 30 35 NCD HFpEF PCWP (mm Hg) PCWP (mm Hg) Obokata, Borlaug Circulation 2017
Cardiopulmonary Exercise Testing Does Not Provide Robust Discrimination of Causes 40 p<0.0001 Peak VO 2 (ml/min/kg) 30 20 10 0 NCD HFpEF Reddy, Borlaug JACC Heart Fail 2018
A simplified, Bayesian Approach to Dx: The H2FPEF Score Reddy, Borlaug Circulation 2018
Cardiac Causes of Dyspnea that may Mimic HFpEF Valvular heart disease Coronary artery disease Pulmonary arterial hypertension High output heart failure Constrictive pericarditis Infiltrative or restrictive cardiomyopathy Hypertrophic cardiomyopathy Right ventricular myopathies Pulmonary embolism
Summary HFpEF is defined by symptoms (i.e. dyspnea) due to failure of the heart to pump blood adequately to the body at normal filling pressures. The diagnosis of HFpEF is made by demonstrating objective evidence of high filling pressures and/or inadequate cardiac output. This is sometimes achieved by physical exam, echocardiography, natriuretic peptide testing and cardiopulmonary exercise testing, but each of these has limitations in sensitivity. Invasive diastolic stress testing represents the gold standard test to identify or rule out HFpEF. The H2FPEF score can be used to estimate the probability that HFpEF is present in patients with unexplained dyspnea and may inform further workup. Remember to exclude disorders that may mimic HFpEF but are treated differently.
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