Challenges in the diagnosis of heart failure with preserved ejection fraction in individuals with obesity

Abstract

The rising prevalence of obesity and its association with heart failure with preserved ejection fraction (HFpEF) highlight an urgent need for a diagnostic approach tailored to this population. Diagnosing HFpEF is hampered by the lack of a single non-invasive diagnostic criterion. While this makes a firm diagnosis of HFpEF already notoriously difficult in the general population, it is even more challenging in individuals with obesity. The challenges stem from a range of factors, including the use of body mass index as a conceptually suboptimal indicator of health risks associated with increased body mass, symptom overlap between HFpEF and obesity, limitations in physical examination, difficulties in electrocardiographic and echocardiographic evaluation, and reduced diagnostic sensitivity of natriuretic peptides in individuals with obesity. In this review, we examine these diagnostic challenges and propose a diagnostic algorithm specifically tailored to improve the accuracy and reliability of HFpEF diagnosis in this growing patient demographic.

Keywords: Diagnosis; Echocardiography; Heart failure with preserved ejection fraction; Natriuretic peptides; Obesity.

Fig. 1

Adjusted Cornell criteria for left ventricular hypertrophy on electrocardiogram. Electrocardiogram of a 60-year-old male patient with obesity class 3 that meets the criteria for left ventricular hypertrophy based on the adjusted Cornell voltage*BMI, (RaVL + SV3)*BMI ≥ 700 mm*kg/m². The diagnosis of left ventricular hypertrophy was confirmed by an echocardiogram. Note that none of the other criteria were positive. BMI, body mass index.

Fig. 2

Measurement of left atrial strain. LA function based on the three phases of the LA cycle: LA reservoir strain, LA conduit strain, and LA contractile strain. LA, Left atrial

Fig. 3

Hypothetical scheme for an obesity-adjusted HFpEF score in individuals with BMI ≥ 30 kg/m². Similar to the HFA-PEFF scoring system, each domain can provide up to 2 points: 2 points are awarded if any major criterion in that domain is met, or 1 point if no major criteria are met but at least one minor criterion is fulfilled. Even if multiple major criteria are satisfied within the same domain, the maximum contribution from that domain remains 2 points. Similarly, if multiple minor criteria are met without any major ones, the domain still only contributes 1 point. Points are not cumulative within the same domain and are only combined when they come from different domains. Disclaimer This is not a validated score, but a hypothetical scheme to provoke thinking about the diagnosis of HFpEF in obesity. E/e’, early diastolic transmitral flow velocity/early diastolic mitral annular velocity; TR, tricuspid regurgitation; GLS, global longitudinal strain; LASr, left atrial strain reservoir phase; LAVh², left atrial volume indexed by height²; LVMh^2.7, left ventricular mass indexed by height^2.7; m/w, men/women; RWT, relative wall thickness; NTproBNP, N-terminal pro B-type natriuretic peptide; BNP, B-type natriuretic peptide; AF, atrial fibrillation; HFpEF, heart failure with preserved ejection fraction.