Echocardiographic Diagnosis of Heart Failure with Preserved Ejection Fraction

Essential Diagnostic Criteria

• The European Society of Cardiology guidelines require three mandatory echocardiographic conditions to be satisfied for the diagnosis of HFpEF, including preserved LV systolic function, evidence of diastolic dysfunction, and structural or functional cardiac abnormalities 1, 2, 3
• The diagnosis of HFpEF requires preserved or only mildly reduced LVEF (≥45-50%) combined with evidence of diastolic dysfunction, structural cardiac abnormalities, or elevated filling pressures to confirm the diagnosis 1, 2

Key Structural Findings

• The European Society of Cardiology guidelines recommend assessing five core structural parameters, including left atrial volume index (LAVI), left ventricular mass index (LVMI), left ventricular hypertrophy, tricuspid regurgitation velocity (TRV), and pulmonary artery pressure 4, 5, 6
• Left atrial volume index (LAVI) is typically elevated, reflecting chronic elevation of filling pressures 4, 5, 6
• Left ventricular mass index (LVMI) is often increased, indicating LV hypertrophy 4, 5, 6

Diastolic Function Parameters

• The E/A ratio is used to assess diastolic function, with three distinct abnormal filling patterns recognized in sinus rhythm, including impaired relaxation pattern, restrictive filling pattern, and pseudonormal pattern 1, 2, 3
• The E/e' ratio is the most established and prognostically validated parameter in HFpEF, though it has only modest correlation with invasive filling pressures (r=0.56) 7, 4, 8
• E/e' >15 indicates high filling pressures, while E/e' <8 suggests low filling pressures 1, 2, 3

Additional Doppler Parameters

• The ESC guidelines detail multiple supplementary Doppler indices, including pulmonary vein flow, (A mitral - A pulmonary) duration, flow propagation velocity (Vp), and E/Vp ratio 1, 2, 3
• Pulmonary vein flow and (A mitral - A pulmonary) duration can be used to assess filling pressures 1, 2

Integrated Assessment Approach

• No single echocardiographic parameter can reliably diagnose HFpEF; an integrated assessment of multiple markers is mandatory 7, 4, 8
• The guidelines emphasize combining structural parameters (LAVI, LVMI), diastolic function indices (E/A, E/e', e'), and hemodynamic markers (TRV, pulmonary pressures) for diagnosis 4, 5, 6, 1, 2, 4

Diagnosing Heart Failure with Preserved Ejection Fraction

Echocardiographic Criteria

• The European Society of Cardiology recommends measuring LVEF ≥45-50% using Simpson's biplane method as the foundational criterion for diagnosing heart failure with preserved ejection fraction (HFpEF) 9
• Assessing for LV global longitudinal strain (GLS) is important, as it may be impaired even with preserved LVEF in HFpEF, with values typically >-18% indicating abnormal longitudinal function 10, 11
• Documenting mitral annular systolic velocity (s') and mitral annular plane systolic excursion (MAPSE) is crucial, as they are often reduced in HFpEF despite preserved LVEF 10

Diastolic Function Parameters

• The American Heart Association suggests that an integrated assessment of multiple parameters, including E/e' ratio, septal e', and lateral e', is necessary for diagnosing HFpEF, with no single measure being sufficient 12, 13
• An E/e' ratio >15 indicates elevated filling pressures, while a ratio <8 suggests normal pressures, and a ratio of 8-15 requires additional parameters 13
• Septal e' <7 cm/sec or lateral e' <10 cm/sec indicates impaired relaxation 10, 13

Structural Abnormalities

• The European Society of Cardiology recommends assessing left atrial volume index (LAVI) >34 mL/m², which reflects chronic elevation of filling pressures 10
• LV mass index (LVMI) >115 g/m² in men and >95 g/m² in women indicates LV hypertrophy 10
• Estimated pulmonary artery systolic pressure (sPAP) from TR jet plus RA pressure is an important parameter in diagnosing HFpEF 11

Excluding HFpEF Mimics

• The American College of Cardiology suggests looking for asymmetric septal hypertrophy (septal/posterior wall thickness ratio >1.3) to exclude hypertrophic cardiomyopathy (HCM) 9, 13
• Assessing for systolic anterior motion (SAM) of the mitral valve and measuring LV outflow tract gradient with continuous wave Doppler are also important in excluding HCM 9
• Pericardial thickness >3-4 mm, respiratory variation in mitral inflow velocities >25%, and septal bounce are indicative of constrictive pericarditis 9

Diagnostic Criteria and Evaluation of Heart Failure with Preserved Ejection Fraction (HFpEF)

Core Diagnostic Requirements (ACC/AHA Guidelines)

• HFpEF is diagnosed only when all three of the following are present:

Frequency and Meaning of “Indeterminate” Diastolic Function

• When current echocardiographic algorithms are applied, ≈10–11 % of studies fall into an “indeterminate” diastolic‑function category, meaning the parameters cannot be confidently classified as normal or abnormal. 15
• An indeterminate result does not constitute proven diastolic dysfunction and therefore cannot, by itself, support a HFpEF diagnosis. 15

Clinical Correlation Required

• Presence of symptoms such as exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or reduced exercise tolerance is mandatory for HFpEF diagnosis. 14
• Presence of signs such as elevated jugular venous pressure, peripheral edema, pulmonary crackles, or an S3 gallop is also mandatory. 14

Additional Diagnostic Tools

• Stress (exercise) echocardiography improves sensitivity for detecting elevated filling pressures in patients whose symptoms appear only with exertion. 15

Key Differential Diagnoses to Exclude (ACC/AHA Guidelines)

• Systematic exclusion of these mimics is essential because they require distinct therapeutic strategies. 14, 17

Bottom‑Line Summary (European Journal of Heart Failure)

• An echocardiogram showing normal systolic function but uncertain diastolic assessment neither confirms nor excludes heart failure; further clinical evaluation and targeted testing are required. 15
• Recommended next steps: