From Primary to Tertiary Care: Expert Position Statements to Guide Heart Failure with Preserved Ejection Fraction Diagnosis

Abstract

Globally, heart failure with preserved ejection fraction (HFpEF) is quickly becoming the dominant form of heart failure (HF) in ageing populations. However, there are still multiple gaps and challenges in making a firm diagnosis of HFpEF in many low-to-middle income Asian countries. In response to this unmet need, the Malaysian HFpEF Working Group (MY-HPWG) gathered and reviewed evidence surrounding the use of different diagnostic modalities indicated for patients with HFpEF to identify diagnostic tools that could be conveniently accessed across different healthcare settings. As a result, five recommendation statements were proposed and an accompanying algorithm was developed, with the aim of improving the diagnostic rate of HFpEF. The MY-HPWG recommends using more easily accessible and non-invasive tools, such as natriuretic peptide (NP) biomarkers and basic echocardiogram (ECHO), to ensure timely HFpEF diagnosis in the primary and secondary care settings, and prompt referral to a tertiary care centre for more comprehensive assessments in uncertain cases.

Keywords: cardiac function; diagnosis; echocardiography; heart failure with preserved ejection fraction; natriuretic peptide.

Figure 1

Recommended diagnostic and referral pathway for patients with HFpEF

Figure 2

Standard initial diagnostic work-up for routine patient evaluation Notes: ADHERE = Acute Decompensated Heart Failure National Registry; AF = atrial fibrillation; CXR = chest X-ray; ECG = electrocardiogram; ED = emergency department; EPICA = Epidemiology of Heart Failure and Learning; HbA1c = haemoglobin A1c; HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction; NP = natriuretic peptide

Figure 3

Left ventricle changes categorised according to relative wall thickness and left ventricular mass index. Reprinted by permission of Oxford University Press (52)