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)
Pieske, Burkert; Tschöpe, Carsten; De Boer, Rudolf A.; Fraser, Alan G.; Anker, Stefan D.; Donal, Erwan; Edelmann, Frank; Fu, Michael; Guazzi, Marco; Lam, Carolyn S.P.; Lancellotti, Patrizio; Melenovsky, Vojtech; Morris, Daniel A.; Nagel, Eike; Pieske-Kraigher, Elisabeth; Ponikowski, Piotr; Solomon, Scott D.; Vasan, Ramachandran S.; Rutten, Frans H.; Voors, Adriaan A.; Ruschitzka, Frank; Paulus, Walter J.; Seferovic, Petar; Filippatos, Gerasimos
(2019) European Heart Journal, volume 40, issue 40, pp. 3297 - 3317
(Article)
Abstract
Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for HF symptoms and signs, typical clinical demographics (obesity,
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hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e′), left ventricular (LV) filling pressure estimated using E/e′, left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F1: Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2: Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.
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Keywords: biomarkers, diagnosis, echocardiography, exercise echocardiography, Heart failure, HFpEF, natriuretic peptides, Cardiology and Cardiovascular Medicine
ISSN: 0195-668X
Publisher: Oxford University Press
Note: Funding Information: Conflict of interest: Dr B.P. has received research funds from Bayer Healthcare, Servier, and Astra-Zeneca, as well as speakers honoraria/committee membership fees from Novartis, Bayer Healthcare, Daiichi-Sankyo, MSD, Stealth Peptides, Astra-Zeneca, Sanofi, Vifor, and Servier. Dr R.A.d.B. is supported by the Netherlands Heart Foundation (CVON DOSIS, grant 2014-40, CVON SHE-PREDICTS-HF, grant 2017-21, and CVON RED-CVD, grant 2017-11); and the Innovational Research Incentives Scheme program of the Netherlands Organization for Scientific Research (NWO VIDI, grant 917.13.350). The UMCG, which employs Dr De Boer has received research grants and/or fees from AstraZeneca, Abbott, Bristol-Myers Squibb, Novartis, Roche, Trevena, and ThermoFisher GmbH. Dr R.A.d.B. received personal fees from MandalMed Inc., Novartis, and Servier. Dr A.A.V. has received consultancy fees and/or research grants from Amgen, Bayer, Boehringer Ingelheim, Merck/Merck Sharp & Dohme, Novartis, Roche Diagnostics, Sanofi Aventis, Servier, Stealth Peptides, Singulex, Sphingotec, Trevena, and Vifor. Dr C.T. received research grants from Novartis and speaker fees from Astra Zeneca, Berlin Chemie, Akcea, Impulse Dynamics, Servier, Bayer, Pfizer, Abbott, Boston Scientific. Dr S.D.A. has received consultancy fees and/or research grants from Abbott Vascular, Bayer, Boehringer Ingelheim, Brahms, Novartis, Servier, Stealth Peptides, and Vifor. Dr C.S.L. is supported by a Clinician Scientist Award from the National Medical Research Council of Singapore; has received research support from Boston Scientific, Bayer, Roche Diagnostics, AstraZeneca, Medtronic, and Vifor Pharma; has served as consultant or on the Advisory Board/ Steering Committee/ Executive Committee for Boston Scientific, Bayer, Roche Diagnostics, AstraZeneca, Medtronic, Vifor Pharma, Novartis, Amgen, Merck, Janssen Research & Development LLC, Menarini, Boehringer Ingelheim, Novo Nordisk, Abbott Diagnostics, Corvia, Stealth BioTherapeutics, JanaCare, Biofourmis, Darma, Applied Therapeutics, MyoKardia, WebMD Global LLC, Radcliffe Group Ltd and Corpus. Patent pending: PCT/ SG2016/050217. Co-founder & non-executive director: eKo.a; Dr W.J.P. is supported by grants from CardioVasculair Onderzoek Nederland (CVON), Dutch Heart Foundation, The Hague, The Netherlands (RECONNECT, EARLY-HFPEF). Dr E.N. has received research grants from Bayer AG and fees/speaker honoraria from Bayer AG and Siemens Healthiness. Dr F.E. reports personal fees from Novartis, grants and personal fees from Boehringer Ingelheim, personal fees from CVRx, Pfizer, Medtronic, Resmed, grants and personal fees from Servier, from MSD, Bayer, Vifor, Berlin Chemie. Dr E.P.-K. reports research grants and consulting fees from Bayer Healthcare and MSD. Dr G.F. received research grants from the European Union and is Committee member of trials and registries sponsored by Novartis, Medtronic, BI, Vifor, Servier, Bayer. The remaining authors have no conflicts of interest to declare. Funding Information: We acknowledge the continuous support of the Heart Failure Association (HFA) for this manuscript. Members of this Task Force were selected by the HFA Board and HFA HFpEF Committee to represent professionals involved with the medical care of patients with HFpEF. Publisher Copyright: © 2019 Published on behalf of the European Society of Cardiology. All rights reserved.
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