Heart Failure With Normal Ejection Fraction

A Growing Pandemic

Satnam Singh; Michael Frenneaux


Future Cardiol. 2012;8(3):383-392. 

In This Article

Diagnosis: What Do Current Guidelines Say?

Most of the published literature and current guidelines share three features for the presence of HFNEF syndrome: clinical signs and symptoms of HF, evidence of normal systolic function and evidence of diastolic dysfunction. Figure 1 summarizes the guidelines currently in practice. HFNEF should be suspected in anyone with a normal LVEF and signs and symptoms of HF. A comprehensive 2D Doppler echocardiogram can easily demonstrate abnormal myocardial relaxation (decreased longitudinal velocity of the mitral annulus during early diastole and decreased propagation velocity mitral inflow), decreased compliance (shortened mitral A-wave duration and mitral deceleration time) and increased filling pressure (shortened isovolumic relaxation time and an increased ratio between early diastolic mitral and mitral annular velocities) in the setting of normal LV dimensions and preserved LVEF.[29] HFNEF is not an isolated disorder of diastole; there are widespread abnormalities of both systolic and diastolic function that become more apparent with exercise.[30] The European Society of Cardiology guidelines require signs or symptoms of HF present along with a LVEF >50%, a LV end diastolic volume index <97 ml/m2, and evidence of diastolic LV dysfunction.[1] LV end diastolic pressure >16 mmHg, pulmonary capillary wedge >12 mmHg and/or E/E' ratio >15 provide standalone evidence of diastolic LV dysfunction. It is also recommended that the natriuretic peptides need to be associated with an E/E' ratio >8, E/A ratio <0.5 + deceleration time (DT) >280 ms, a pulmonary vein flow velocity signal showing a duration of reverse pulmonary vein atrial systole flow–duration of mitral valve atrial wave flow >30 ms, a LA size >40 ml/m2, or a LV mass >149 g/m2 (men) or >122 g/m2 (women).

Figure 1.

Heart failure with normal ejection fraction guidelines.
Ad: Duration of mitral valve atrial wave flow; Ard: Duration of reverse pulmonary vein atrial systole flow; DT: Deceleration time; ESC: European Society of Cardiology; HFNEF: Heart failure with normal ejection fraction; IVRT: Intraventricular relaxation time; LAE: Left atrial enlargement; LVEDP: Left ventricle end diastolic pressure; LVEDVI: Left ventricular end diastolic volume index; LVH: Left ventricle hypertrophy; NHLBI: National Heart, Lung, and Blood Institute; PCW: Pulmonary capillary wedge; PVV: Pulmonary vein velocity.
Data taken from.60-63

Recently Borlaug et al. convincingly demonstrated that an exercise pulmonary artery systolic pressure ≥45 mmHg identified HFpEF with 96% sensitivity and 95% specificity.[31]


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