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INTRODUCTION

ESSENTIALS OF DIAGNOSIS

  • Preserved left ventricular ejection fraction (LVEF ≥ 50%).

  • Presence of the signs and symptoms of heart failure resulting from any structural or functional impairment of ventricular filling or ejection of blood, such as:

    • Abnormal cardiac chamber enlargement, echocardiographic evidence of left ventricular diastolic dysfunction, moderate/severe ventricular hypertrophy or moderate/severe valvular obstructive or regurgitant lesion.

  • Evidence of spontaneous or provokable increased LV filling pressures, such as:

    • Elevated natriuretic peptide level (eg, BNP, NT-proBNP).

    • Noninvasive and invasive hemodynamic measurement.

GENERAL CONSIDERATIONS

Heart failure with preserved ejection fraction (HFpEF) is an increasingly recognized, debilitating syndrome, and carries a high rate of morbidity and mortality. HFpEF accounts for more than 50% of all hospitalizations for heart failure (HF). Survival for all HF patients is equally as poor regardless of underlying ejection fraction, especially after HF hospitalization. It is a heterogeneous syndrome, and categorizing patients based on their underlying pathophysiology and comorbidities is the key to treatment.

HFpEF is the preferred term for patients with a normal ejection fraction who have the syndrome of HF because HFpEF highlights the fact that HF is a syndrome and not a distinct clinical or pathophysiologic entity. The terminology of “diastolic heart failure” and “systolic heart failure” is now obsolete. By calling HFpEF “diastolic HF,” clinicians may not consider the entire differential diagnosis and syndrome of HFpEF. HFpEF has also previously been called “HF with preserved systolic function” or “HF with normal systolic function.” Patients with HFpEF have abnormalities in longitudinal systolic function (as defined by tissue Doppler imaging and speckle-tracking echocardiography) despite a normal ejection fraction, and patients with HF with reduced EF (HFrEF) often have abnormal diastolic function.

In 2021, the Heart Failure Society of America (HFSA), the Heart Failure Association of the European Society of Cardiology (HFA-ESC), and the Japanese Heart Failure Society (JHFS) jointly published a new Universal Definition and Classification of Heart Failure. Patients with HF are classified based on ejection fraction into three categories: reduced ejection fraction (< 40%), mildly reduced ejection fraction (40–50%), and preserved ejection fraction (> 50%). Further, to capture improvements in ejection fraction seen with contemporary guideline-directed medical therapy (GDMT), they introduced “HF with improved EF” as HF with a baseline LVEF ≤ 40%, a ≥ 10-point increase from baseline LVEF, and a second measurement of LVEF more than 40%.

In 2022, the American College of Cardiology (ACC), the American Heart Association (AHA), and the HFSA released an updated Guideline for the Management of Heart Failure. This guideline statement serves as a key reference for the prevention, diagnosis, and management of patients with heart failure. To have a diagnosis of HFpEF, patients must have evidence of increased LV filling pressures at rest, exercise, or other provocations. This is manifested by invasive hemodynamic measurement at rest or exercise, echocardiographic diastolic parameters (eg, E/e′ ≥ 15) or other evidence of elevated filling ...

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