HFpEF: Common Disease, Uncommon Diagnosis
HFpEF: Common Disease, Uncommon Diagnosis
Source: Medscape Medical News
Date: December 09, 2025
Keynotes:
1. HFpEF: A Rising Clinical Challenge
• HFpEF causes HF symptoms despite LVEF ≥ 50% due to elevated LV filling pressures.
• HFpEF is commonly underdiagnosed because its symptoms resemble those of many noncardiac illnesses.
• Prevalence is rising, especially in older adults, women, and obesity.
2. Why Diagnosis Is Often Missed or Delayed
• One-third of HFpEF patients have normal filling pressures at rest; abnormalities appear only during exercise.
• Patients with obesity waited 22 months on average to receive the correct diagnosis.
• Many dismiss exertional dyspnea as aging → 11-month average delay before even visiting a primary provider.
3. • Among HFpEF subtypes, the obesity-related form is relatively easier to recognize due to its well-defined clinical features.
4. Invasive hemodynamic testing remains essential in patients who have normal filling pressures at rest but persistent clinical suspicion. It can uncover:
• Elevated filling pressures that appear only during exercise
• Patterns that help differentiate left-heart HFpEF from pulmonary vascular involvement
Its main limitations include procedural complexity and limited availability.
• Research aims to replace invasive testing with noninvasive surrogates (imaging, biomarkers).
5. HFA-PEFF (ESC 2019)
• Comprehensive algorithm combining:
• Clinical findings (signs & symptoms)
• Echocardiography
• Biomarkers
• And, in selected cases, complex invasive hemodynamic testing, such as right heart catheterization performed:
– at rest then
– after a fluid challenge (e.g., 500 mL saline)
• More accurate rule-in / rule-out for HFpEF than simpler scores.
• Usually applied in specialized centers rather than routine clinics.
6. AI-Based Tools: Promising but Not Yet Ready
• ECG-AI models classify HF types using ECG plus echo-derived EF.
• Echo-AI models using a single 4-chamber image estimate HFpEF probability.
• Early promise, but insufficient accuracy for routine clinical use.
7. Refinements in Diagnostic Testing
• Fluid challenge (500 mL over 5 min): PCWP >18 mmHg → supports HFpEF.
• Stress echocardiography detects abnormal diastolic filling but needs high expertise.
• Progress aims to reduce reliance on exercise RHC in the future.
8. Biomarkers: Why NT-proBNP Falls Short in HFpEF
A) Biological limitation
• HFpEF has less myocardial stretch → lower natriuretic peptide release.
• Many HFpEF patients—especially with obesity—have normal BNP/NT-proBNP despite true hemodynamic burden.
• Resting biomarkers fail to capture exercise-only congestion.
Sensitivity at standard cut-offs (125 pg/mL)
• Non-obese: sensitivity ~80–88% (misses 12–20%).
• Obesity (BMI ≥35): sensitivity ~55–67% (misses up to 45%).
• In several series: <50% sensitivity in obese patients.
C) Lowering the cut-off (<50 pg/mL)
• Improves sensitivity:
• 97% (non-obese)
• ~86% (obese)
• But markedly lowers specificity → more false positives.
D) Clinical impact
• Normal NT-proBNP does NOT exclude HFpEF, especially in:
• Obesity
• Early disease
• Exertional symptoms
• Biomarkers must be combined with clinical scores, imaging, and functional hemodynamics.
9. Emerging Biomarkers and Future Directions (Simplified)
• Because NT-proBNP often fails to detect HFpEF, especially in obesity and early disease, researchers are searching for better blood markers that can reflect diastolic pressure and congestion more accurately.
• Promising candidates include soluble ST2, inflammatory markers, and fibrosis markers.
• No biomarker is reliable enough yet to diagnose HFpEF across all patient groups.
10. Improving Referral Pathways
• More internists now refer directly to HF specialists or simultaneous cardiology + pulmonology evaluation.
• Early testing (NT-proBNP + echo) in dyspnea with obesity or age-related risk helps reduce diagnostic delay.
11. The Bottom Line
HFpEF diagnosis continues to lag because resting biomarkers underperform, congestion often appears only with exertion, and obesity masks peptide levels. Accurate diagnosis requires integrating natriuretic peptides with structured algorithms, imaging, and—in selected cases—invasive hemodynamic assessment.
Link: https://www.medscape.com/viewarticle/cracking-hfpef-are-diagnostic-methods-evolving-2025a1000yi5?
