Does My Patient With Multiple Comorbidities Have Heart Failure With Preserved Ejection Fraction, and Does It Matter?

Dmitry Abramov, MD


J Am Board Fam Med. 2019;32(3):424-427. 

In This Article

Defining Heart Failure With Preserved Ejection Fraction

Heart failure has been defined as the inability of the heart to generate adequate cardiac output or the ability to generate adequate cardiac output only in the setting of elevated filling pressures.[4] The standard clinical diagnostic criteria for HFpEF includes heart failure symptoms (such as dyspnea, orthopnea, paroxysmal nocturnal dyspnea) and elevated filling pressures (predominantly Wedge pressure) at rest or with exercise.[5] Elevated filling pressures may be clinically estimated through measurement of jugular venous distention. Confirmation of elevated filling pressures, and therefore the heart failure diagnosis, can be obtained through invasive right heart catheterization. The history and physical examination-derived signs and symptoms suggestive of heart failure may be difficult to ascertain, and their correlation with invasively derived filling pressures has largely been based on studies of acutely decompensated or end-stage patients with reduced ejection fraction.[1,6] Recently, permanently implanted pulmonary artery monitors have been used to help evaluate central filling pressures as a supplement to the physical examination,[7] although the utility of such devices as part of the diagnostic evaluation of heart failure may be limited.

Current diagnostic criteria for HFpEF from the American College of Cardiology and American Heart Association include clinical signs or symptoms, ejection fraction ≥50%, and evidence of diastolic dysfunction.[1] Patients meeting heart failure criteria with ejection fraction of 41% to 49% can be classified as having heart failure with borderline or midrange ejection fraction, which is more clinically similar to HFpEF than to heart failure with reduced ejection fraction.[1,8] Diagnostic criteria for HFpEF from the European Society of Cardiology are similar, and include signs and symptoms, ejection fraction of ≥50%, elevated B-type natriuretic peptide values and echocardiographic evidence of structural abnormalities or diastolic dysfunction.[9]