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Heart failure with preserved ejection fraction (HFpEF) is characterized by typical signs and symptoms of heart failure, a preserved left ventricular ejection fraction, and functional and/or structural alterations of left ventricular function.
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Comorbidities (eg, chronic obstructive pulmonary disease, renal insufficiency) are frequent and may cause similar symptoms as HFpEF, and therefore must be addressed in the differential diagnosis.
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Different clinical settings for HFpEF are discussed.
Diagnosis of Heart Failure with Preserved Ejection Fraction
Section snippets
Key points
Physical Examination
Clinical findings in HFpEF do not substantially differ from those in HFrEF. Specific findings during physical examination are elevated jugular venous pressure, hepatojugular reflux, third heart sound, laterally displaced apical impulse, and cardiac murmur. Peripheral edema, especially at the ankles, is common and pulmonary crepitations are often heard, especially if the onset of symptoms is acute. Physical examination should also focus on common comorbidities (eg, anemia, chronic kidney
Differential diagnosis and diagnostic dilemmas
Patients complaining of dyspnea are not necessarily considered to have heart failure. Differential diagnoses are numerous and are listed in Box 1.
Dyspnea on exertion is the major complaint in patients being evaluated in cardiac outpatient clinics. However, these patients may also be seen initially by pneumologists, and therefore need to be referred for further cardiologic workup. The consensus document of the ESC working groups provides reasonable algorithms for ruling in and out HFpEF.3 The
Case studies
In general, in the authors’ experience, HFpEF has 2 distinct clinical presentations (Table 3). Past HFpEF trials have reported on both of these entities.
Currently, whether these are actually 2 different entities or the same disease at different stages is unclear. Ongoing prospective observational trials (eg, Diast-CHF) and epidemiologic trials are currently investigating the incidence and clinical predictors of progression from the early to the late presentation.
Summary
Diagnosing HFpEF is challenging. Patients may present with different clinical pictures; they may be hospitalized for heart failure, complaining of dyspnea on exertion, or scheduled for right cardiac catheterization with echocardiographic signs of pulmonary hypertension.
In addition to a thorough evaluation of signs and symptoms, minimal diagnostics should include electrocardiography, echocardiography, and laboratory testing. In many cases, right heart catheterization or exercise testing should
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Conflict of Interest: None.