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Diagnosing heart failure with preserved ejection fraction: The new HFA consensus

Diagnostic Methods
Heart Failure

Burkert Pieske.jpgProf. Burkert Pieske

Heart failure with preserved ejection fraction (HFpEF) is a disorder with multiple risk factors and comorbidities. Professor Burkert Pieske (Charité – Universitätsmedizin Berlin, Berlin, Germany), HFA Committee on Heart Failure Preserved Ejection Fraction Member and a presenter in Monday’s session discussing the new HFA consensus paper on HFpEF, outlines why the HFA decided to provide these new diagnosis guidelines and what they mean for doctors and patients.

“Patients with HFpEF are typically elderly, overweight and often females, with predisposing comorbidities, such as hypertension and metabolic syndrome. It is difficult for the doctor faced with this sort of patient—presenting with non-specific heart failure-like symptoms, such as reduced exercise capacity, dyspnoea on exertion and ankle oedema—to differentiate a cardiac origin from extracardiac causes of the complaints. This is a frequently encountered problem in daily clinical practice. The HFA wanted to provide recommendations that would help doctors in diagnosing or excluding HFpEF in these patients,” explains Prof. Pieske.

Developed by an international panel, the new HFA expert consensus paper, which is due to be published in the European Journal of Heart Failure and the European Heart Journal in the coming months, is built around four diagnostic steps.

“The first step can be conducted by a patient’s first point of contact, including a GP or internist, and doesn’t require specialist assistance,” he says. “It involves assessing the pre-test probability that heart failure is the cause of a patient’s symptoms and it combines an assessment of risk factors and medical history, with ECG analysis and laboratory tests, including haemoglobin and natriuretic peptide (NP), a standard echocardiogram to assess left ventricular ejection fraction and an exercise test.” If the evidence points towards HFpEF as the underlying cause, patients should proceed to the second step, which Prof. Pieske describes as the most innovative part of the recommendations. “A sophisticated echocardiographic work-up in conjunction with NP levels (stratified by the presence or absence of atrial fibrillation) will result in an individual HFpEF likelihood score (no abnormal HFpEF findings: 0 points; highly abnormal HFpEF findings most prevalent: 6 points), which is meant to confirm (5 or 6 points) or exclude (<2 points) HFpEF. Patients in the grey zone, that is those with a score of 2–4 points, should proceed to step 3, where exercise testing in combination with echocardiography or invasive haemodynamics is used to confirm or exclude a suspected diagnosis,” he explains. The final step is, according to Prof. Pieske, essential for the effective treatment of patients with a confirmed diagnosis of HFpEF. “Step 4,” he says, “is about assessing the underlying aetiology and pathophysiology—generally with magnetic resonance imaging, sophisticated laboratory measures and/or myocardial scintigraphy or biopsy. This crucial information will enable the heart failure specialist to tailor treatment to that patient.” Summing up, Prof. Pieske was clear about the benefits of this four-step diagnostic approach. “There are millions of individuals with heart failure-like symptoms. These recommendations provide doctors with a relatively quick, accessible and staged way of identifying which of these patients have underlying HFpEF and determining the optimum treatment approach for each patient.”