ESC 2022: Heart Failure with Preserved Ejection Fraction as an Underdiagnosed Problem: How to Increase Its Detection in Everyday Practice?
During this year's European Society of Cardiology Congress (ESC 2022), alarming information was shared, indicating that heart failure with preserved ejection fraction of the left ventricle (HFpEF) is likely underdiagnosed in clinical practice, necessitating improved identification and detection of patients with this condition. One of the symposiums addressed not only the reasons why many patients with HFpEF are misdiagnosed.
Are HFpEF Patients Overlooked?
Watch for Early Stages
Dr. Ileana L. Piña from Thomas Jefferson University in Philadelphia noted that in patients with preserved LV EF, many common signs of heart failure (HF) appear only in advanced disease. Early stages of HFpEF often present with only nonspecific symptoms associated with exertion, which are broadly prevalent in the older population (shortness of breath, reduced physical activity tolerance, fatigue, exhaustion, prolonged recovery time after physical activity). This significantly complicates the differential diagnosis of HFpEF, which often manifests with ≤ 2 symptoms, with exertional dyspnea and fatigue being the most common—such patients constituted 62% in the PARAGON-HF trial [1].
Poor Outcomes, Heavy Burden, Higher Prevalence
In the population over 65, heart failure is the most common cause of hospitalization. Patients with preserved LV EF make up an increasing proportion of those with HF (now > 50%), and approximately 30% of individuals hospitalized for HFpEF die within 1 year; the 5-year mortality is similar for HFpEF and HF with reduced EF (HFrEF) [2]. A prospective study conducted in the US suggested that older adults with acute decompensated HFpEF consistently have worse health status than those with HFrEF [3]. In practice, patients with HFpEF are often labeled as hypertensive, obese/overweight, diabetic, and/or with chronic kidney disease [4].
Finding HFpEF in Practice
Dr. Maria Rosa Costanzo from Advocate Heart Institute in Naperville summarized what doctors should focus on in practice.
Evidence Often Requires Invasive Testing
She initially discussed the case of a 64-year-old man with unexplained fatigue, reporting loss of energy and feeling fatigued by 2 PM on working days. An echocardiogram showed normal LV EF (55%) and grade 1 diastolic dysfunction. Invasive hemodynamic testing (right heart catheterization) of pulmonary artery pressure and pulmonary capillary wedge pressure (PCWP) at rest and during exertion confirmed HFpEF—PCWP significantly increased with exertion. The presenter noted that without this invasive method, and testing pressures during exertion, HFpEF in this man would have gone undiagnosed. This was already a cardiac patient with atrial fibrillation (AF), also being treated for obstructive sleep apnea with CPAP.
Score-Based Algorithms—Diagnosis Aides
The reference standard for diagnosing HFpEF is hemodynamic testing during exertion using heart catheterization. HFpEF patients have higher PCWP during exertion, directly linked to increased dyspnea and mortality. Score-based algorithms—H2FPEF and HFA-PEFF—aid in diagnosing HFpEF.
The H2FPEF score is based on 6 clinical and echocardiographic characteristics, distinguishing HFpEF from non-cardiac causes of dyspnea and helps decide if further testing is needed. It integrates 6 predictive variables: BMI, presence of hypertension, AF, pulmonary hypertension, age, and LV filling pressure (E/e' ratio) [5].
HFA-PEFF (Heart Failure Association Pre-test assessment, Echocardiographic and natriuretic peptide score, Functional testing in case of uncertainty, Final aetiology) is a scoring system proposed by the Heart Failure Working Group of the European Society of Cardiology (HFA-ESC), including echocardiographic parameters (functional and morphological) and biomarkers (natriuretic peptide levels). It's part of a 4-step diagnostic algorithm from clinical assessment to invasive tests in case of diagnostic uncertainty, helping establish the specific cause of HFpEF or provide an alternative explanation for exertional dyspnea [6].
Eva Srbová
proLékaře.cz Editorial Team
Sources:
1. Jering K., Claggett B., Redfield M. M. et al. Burden of heart failure signs and symptoms, prognosis, and response to therapy: the PARAGON-HF trial. JACC Heart Fail 2021; 9 (5): 386–397, doi: 10.1016/j.jchf.2021.01.011.
2. Owan T. E., Hodge D. O., Herges R. M. et al. Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med 2006; 355 (3): 251–259, doi: 10.1056/NEJMoa052256.
3. Warraich H. J., Kitzman D. W., Whellan D. J. et al. Physical function, frailty, cognition, depression, and quality of life in hospitalized adults ≥60 years with acute decompensated heart failure with preserved versus reduced ejection fraction. Circ Heart Fail 2018; 11 (11): e005254, doi: 10.1161/CIRCHEARTFAILURE.118.005254.
4. Pina I. When you can't see the wood for the trees: are we missing patients with HFpEF? The elephant in the room: finding HFpEF in daily practice. ESC Congress, Barcelona, 2022 Aug 27.
5. Reddy Y. N. V., Carter R. E., Obokata M. et al. A simple, evidence-based approach to help guide diagnosis of heart failure with preserved ejection fraction. Circulation 2018; 138 (9): 861–870, doi: 10.1161/CIRCULATIONAHA.118.034646.
6. Pieske B., Tschöpe C., de Boer R. A. 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 (40): 3297–3317, doi: 10.1093/eurheartj/ehz641.
7. Costanzo M. R. Finding HFpEF in practice: what do we need to watch out for? The elephant in the room: finding HFpEF in daily practice. ESC Congress, Barcelona, 2022 Aug 27.
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