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Early diagnosis: key to improving HFpEF outcomes?

Comment by Andreas Gevaert, Secondary Prevention and Rehabilitation Section

Preventive Cardiology
Chronic Heart Failure
Risk Factors and Prevention

Many patients with heart failure and preserved ejection fraction (HFpEF) present at an early stage with complaints of exercise intolerance or exertional dyspnea. But resting examinations, including echocardiography and resting right heart catheterization, may be completely normal at this stage.(1) Hence the importance of "stressing" a dyspneic patient using exercise, this may unmask a pathological diastolic reserve as well as other abnormalities of exercise physiology associated with HFpEF.(2,3)

Exercise hemodynamics are the gold standard to diagnose HFpEF at an early stage, but this examination is not universally available, requires a high level of expertise, and is invasive with risk of complications. Echocardiography has reasonable "rule in" capacity especially when combined with cardiopulmonary exercise testing (CPETEcho).(4) The authors of this paper in the Journal revisited all exercise echos performed, and assessed outcomes according to the Heart Failure Association PEFF score (HFA-PEFF).(5) The HFA-PEFF score is subdivided in a "resting" score (maximum of 6 points) based on natriuretic peptide levels and echocardiography parameters.(6) Patients with exertional dyspnea or exercise intolerance scoring 0-1 points have <25% risk of HFpEF, those scoring ≥5 points have a >90% risk of HFpEF, and the remaining patients have an intermediate probability.(7) In these latter patients, exercise echocardiography is recommended, and high exercise E/e' or pulmonary artery pressures can add 2-3 points to the score.(6)

The authors found that, among patients with exertional dyspnea, those who received a diagnosis of early HFpEF had worse outcomes (mortality or heart failure event) compared to those with non-cardiac dyspnea. Moreover, those who had HFA PEFF score <5 at rest, but added points during exercise stress, had similar outcomes to the other HFpEF patients.

But there is hope for those with early HFpEF: patients who received early intervention had better outcomes! Of note, intervention was mainly diuretics or sodium-glucose cotransporter 2 inhibition in this study, but in general exercise training and weight loss therapy should be part of a HFpEF therapeutic strategy.

Taking into account some limitations, such as the retrospective design and referral bias, this study provides a ground for further research to diagnose HFpEF earlier using exercise echocardiography, possibly improving outcomes in these patients.


Andreas Gevaert commented on:

5. Saito Y, Obokata M, Harada T, et al. Prognostic benefit of early diagnosis with exercise stress testing in heart failure with preserved ejection fraction. Eur J Prev Cardiol 2023; zwad127.

Additional references:

1.     Gevaert AB, Kataria R, Zannad F, et al. Heart failure with preserved ejection fraction: recent concepts in diagnosis, mechanisms and management. Heart 2022; 108: 1342–1350.
2.     Borlaug BA, Olson TP, Lam CSP, et al. Global Cardiovascular Reserve Dysfunction in Heart Failure With Preserved Ejection Fraction. J Am Coll Cardiol 2010; 56: 845–854.
3.     Borlaug BA, Nishimura RA, Sorajja P, Lam CSP, Redfield MM. Exercise hemodynamics enhance diagnosis of early heart failure with preserved ejection fraction. Circ Heart Fail 2010; 3: 588–595.
4.     Verwerft J, Bertrand PB, Claessen G, Herbots L, Verbrugge FH. Cardiopulmonary Exercise Testing With Simultaneous Echocardiography. JACC Heart Fail 2023; 11: 243–249.
6.     Pieske B, Tschöpe C, de Boer RA, et al. 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). Eur Heart J 2019; 40: 3297–3317.
7.     Churchill TW, Li SX, Curreri L, et al. Evaluation of 2 Existing Diagnostic Scores for Heart Failure With Preserved Ejection Fraction Against a Comprehensively Phenotyped Cohort. Circulation 2021; 143: 289–291.

Notes to editor

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.