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

Limitations of Diagnostic Criteria for HFpEF

While seemingly straightforward, the application of these criteria to the community setting is fraught with limitations. These diagnostic criteria have been criticized for low sensitivity,[2] and the reliance on echocardiographic evaluation of diastolic dysfunction may neither accurately evaluate cardiac relaxation abnormalities nor contain sufficient sensitivity or specificity to detect a clinical course consistent with HFpEF.[10] Although exact criteria for grading of diastolic dysfunction have changed over time,[11] diastolic abnormalities on echocardiography are common in community cohorts of patients with comorbidities such as obesity, hypertension, diabetes and coronary disease,[12] and have poor correlation with heart failure symptoms.[12,13] In addition, only minimal abnormalities in diastolic parameters (including a high prevalence of normal diastolic function, normal left atrial size, and normal wall thickness) are noted in cohorts with symptomatic HFpEF.[10] Echocardiographic diastolic parameters may primarily estimate ventricular filling pressures,[11] rather than necessarily providing an explanation for their elevation.

Clinical trials and day-to-day care of patients with HFpEF highlight the high burden of comorbidities associated with this condition. Common noncardiac comorbidities include older age, chronic kidney disease, and lung disease. Common cardiac comorbidities include diabetes, hypertension, coronary artery disease, obesity and atrial fibrillation. As dyspnea is a common symptom in patients with many of these comorbidities, and given the notable limitations of the diagnostic algorithms, how are clinicians to identify which of these patients may have HFpEF?

In light of these limitations, some have proposed scoring systems to help identify patients with HFpEF among those being evaluated for dyspnea;[5] identifying that the biggest predictors of elevated filling pressures (and therefore the HFpEF diagnosis) among patients with dyspnea are advanced age (>60 years old), obesity (Body Mass Index >30 kg/m2) and atrial fibrillation. Other factors having a smaller association with elevated filling pressures include elevated pulmonary artery systolic pressure, treatment with multiple antihypertensive medications, and abnormal diastolic parameter of E/e'.[5] Having the 3 risk factors of advanced age, obesity, and atrial fibrillation was associated with a greater than 90% likelihood of meeting criteria for the diagnosis of HFpEF based on elevated filling pressures.[5] Importantly, elevated B-type natriuretic peptide, dilated left atrium, ventricular hypertrophy, or abnormal ventricular strain—all key parameters associated with diastolic dysfunction—had either smaller or no independent predictive ability to diagnose elevated filling pressures.

This focus on comorbidities as the key contributor to pathophysiology of HFpEF raises significant questions about our current understanding of what it means to impart onto a patient the heart failure diagnosis. Dyspnea is a ubiquitous and subjective symptom in older individuals,[14] and is particularly common in patients with comorbidities including obesity and atrial fibrillation. Dyspnea may also be multifactorial, and not primarily caused by elevation in intracardiac filling pressures.[15] Elevated filling pressures, even in the presence of dyspnea, may not always reflect heart failure, as every patient with end-stage renal disease on dialysis is not generally considered to have "heart failure" before a dialysis session.