How to diagnose heart failure with preserved ejection fraction: the value of invasive stress testing

Abstract

Heart failure with preserved ejection fraction (HFpEF) is a growing healthcare burden worldwide and its prevalence is increasing. Diagnosing HFpEF is challenging and relies upon the presence of symptoms and/or signs of heart failure, preserved left ventricular systolic function, and evidence of diastolic dysfunction. Current diagnostic algorithms mainly rely on echocardiography (E/e') and biomarkers (NT-proBNP). However, only a minority of patients with HFpEF are identified, and especially HFpEF patients at an early stage of the disease are easily missed. We propose to incorporate invasive stress testing, by means of right heart catheterisation at rest and during exercise, and accurate assessment of right ventricular function, by means of cardiac magnetic resonance imaging. These additions to the current diagnostic work-up will improve diagnostic sensitivity and accurate staging of HFpEF patients.

Keywords: Diagnosis; Diastole; Echocardiography; Exercise test; Heart failure; Swan-Ganz catheterisation.

Fig. 1

How to diagnose HFpEF. We propose ‘elevated PCWP during exercise’ as a new criterion for (early) HFpEF. LVEF left ventricular ejection fraction, LVEDVi indexed left ventricular end-diastolic volume, PWCP pulmonary capillary wedge pressure, dec.time deceleration time, LAVi indexed left atrial volume, LVMi indexed left ventricular mass, LVEDP left ventricular end-diastolic pressure

Fig. 2

At rest, left ventricular filling pressures might be normal (LVEDP or PCWP < 15 mmHg), even though the left ventricular end-diastolic pressure-volume relationship is already disturbed/steepened. Invasive measurements during exercise can be helpful in unmasking significant diastolic impairment (early HFpEF)

Fig. 3

VUmc diagnostic work-up for HFpEF (‘Zorgpad: Diastolisch Hartfalen’). Referred patients with a clinical suspicion of HFpEF will undergo right heart catheterisation at rest and during exercise, as well as CMR. Either an alternative diagnosis is found, or HFpEF is confirmed and staged according to findings as: early HFpEF, advanced HFpEF, with or without post- or combined post- and pre-capillary pulmonary hypertension (PH), and with or without right ventricular (RV) dysfunction. OSAS obstructive sleep apnoea syndrome, PAH pulmonary arterial hypertension