Evolution of a Geriatric Syndrome: Pathophysiology and Treatment of Heart Failure With Preserved Ejection Fraction

Bharathi Upadhya, MD; Barbara Pisani, MD; Dalane W. Kitzman, MD


J Am Geriatr Soc. 2017;65(11):2431-2440. 

In This Article

Diagnosis of HFpEF

Evaluation of new-onset HF in older adults should include an imaging test, such as an echocardiogram. An echocardiogram will not only assess systolic function, but may also discover unexpected but important diagnoses, such as valvular abnormalities, large pericardial effusion, hypertrophic obstructive cardiomyopathy, and cardiac amyloidosis. Although echocardiography is an important initial test, HFpEF is not necessarily an echocardiographic diagnosis, although the echocardiogram can provide helpful supportive findings in addition to identifying other causes of HF symptoms. The 2013 American College of Cardiology/American Heart Association (ACC/AHA) Consensus Guidelines defined HFpEF largely as a diagnosis of exclusion: typical symptoms and signs of HF, preserved EF on an imaging study, and no other obvious cause to explain the individual's symptoms such as marked anemia or thyroid dysfunction.[12] As suggested in the 2017 ACC/AHA Focused Update on HF, measurement of natriuretic peptide biomarkers (B-type natriuretic peptide (BNP) or N-terminal pro BNP (NT-proBNP)) can be helpful in the diagnosis of HF,[12] although multiple studies have reported that natriuretic peptides are significantly lower in individuals with HFpEF than in those with HFrEF[13] and that natriuretic peptide levels are inversely related to body mass index, which is highly relevant because obesity is common in individuals with HFpEF.[14] Natriuretic peptide levels are paradoxically inversely related to treatment benefit,[15] and their change does not correlate well with symptom improvement.[16] In addition, BNP levels increase with age in normal populations free of left ventricular (LV) dysfunction,[17] and female sex is an independent predictor of BNP levels in older adults, even those without cardiac dysfunction.[18] Thus age and sex can affect BNP and NT-proBNP levels, further reducing their diagnostic value in older persons.[17,18] Therefore, we believe that HFpEF is a clinical diagnosis, and that the ACC/AHA guidelines are appropriate for clinical practice.