HF with preserved ejection fraction
Proving raised filling pressure — at rest, with scores, or during exercise — and finding the specific cause.
Numbers to remember
- LVEF ≥50% with symptoms and objective evidence of raised filling pressure [12,37]
- H₂FPEF: BMI >30 (2), ≥2 antihypertensives (1), AF (3), PASP >35 (1), age >60 (1), E/e′ >9 (1); ≥6 = likely [102]
- HFA-PEFF: ≥5 points = HFpEF; 2–4 → diastolic stress test or invasive testing [101]
- Exercise: average E/e′ >14 with TR >3.4 m/s supports HFpEF [101,105]
- LA reservoir strain <18% supports raised LAP when conventional indices are indeterminate [32,99]
Questions echo must answer
HFpEF is heart failure with LVEF ≥50% and objective evidence of cardiac structural or functional abnormalities consistent with raised LV filling pressure [12,37]. The problem is that filling pressures are often normal at rest. Echo proves the diagnosis with rest indices, validated scores and, when needed, a diastolic stress test [101,102,105,106]. It also finds specific causes that have their own treatment [100].
- Is filling pressure raised at rest?e′, E/e′, TR velocity, LAVI, then LA strain or pulmonary vein flow when indeterminate [2,32].
- Structural substrateLV mass and RWT, LA size and function [1,101].
- ProbabilityH₂FPEF or HFA-PEFF [101,102].
- If intermediateDiastolic stress echo [105,106].
- Specific causes and mimicsAmyloidosis, HCM, constriction, valve disease, high-output states, PH [30,57,100].
- CouplingArterial stiffness and ventricular–vascular coupling are part of the phenotype [161,162].
Acquisition protocol
- PLAXLV walls, RWT and LV mass (ASE cube formula) [1,41].
- A4C / A2CBiplane LVEF and LAVI at end-systole with LA-focused views [1].
- Mitral inflowE, A, E/A, DT at the leaflet tips [2].
- Tissue DopplerSeptal and lateral e′; average E/e′ [2,32].
- TR CWPeak velocity from several windows [3].
- LA strainReservoir strain, if the four standard indices disagree or are indeterminate [32,163,165].
- Pulmonary veinsS/D ratio, Ar–A duration [2].
- RVTAPSE, TAPSE/PASP [52].
- ExerciseSupine bicycle: E/e′ and TR velocity at peak and in early recovery [105,106].
- LVEF ≥50%
- LV mass index and RWT
- e′ septal and lateral, average E/e′
- TR velocity
- LAVI
- LA reservoir strain (if needed)
- Diastolic grade
- H₂FPEF and HFA-PEFF
- Specific causes considered (amyloid, HCM, constriction, valves)
Diagnosis & severity
Rest indices of raised LV filling pressure [2,32]
| Index | Abnormal |
|---|---|
| Average E/e′ | >14 |
| Septal / lateral e′ | <7 / <10 cm/s |
| TR peak velocity | >2.8 m/s |
| LAVI | >34 mL/m² |
| LA reservoir strain | <18% (supportive) |
H₂FPEF score [102]
| Item | Points |
|---|---|
| Heavy: BMI >30 kg/m² | 2 |
| Hypertensive: ≥2 antihypertensives | 1 |
| Atrial fibrillation | 3 |
| Pulmonary hypertension: PASP >35 mmHg | 1 |
| Elder: age >60 | 1 |
| Filling pressure: E/e′ >9 | 1 |
A score of 0–1 makes HFpEF unlikely; ≥6 makes it likely. Intermediate scores need further testing [102].
HFA-PEFF step 2 (echo and natriuretic peptide) [101]
Major criteria score 2 points and minor criteria 1 point in each domain (functional, morphological, biomarker). ≥5 = HFpEF; 2–4 = diastolic stress test or invasive haemodynamics.
- Functional. Major: septal e′ <7 or lateral e′ <10 cm/s, average E/e′ ≥15, or TR >2.8 m/s. Minor: E/e′ 9–14 or GLS <16%.
- Morphological. Major: LAVI >34 mL/m², or LV mass index ≥149/122 g/m² (men/women) with RWT >0.42. Minor: LAVI 29–34, LV mass index >115/95, RWT >0.42 or wall ≥12 mm.
Thresholds that change management
- Probable HFpEF → SGLT2 inhibitor (DELIVER showed fewer HF events) [82], diuretics for congestion, and treatment of hypertension, AF and obesity [12]. Tirzepatide reduced LV mass in obesity-related HFpEF [84].
- Intermediate probability → diastolic stress echo. A rise in average E/e′ >14 (or septal >15) with TR velocity >3.4 m/s adds points in HFA-PEFF [101,105,106].
- Red flags for a specific cardiomyopathy (wall ≥12 mm, low s′, apical sparing) → amyloid work-up [30].
- High PASP with a normal-looking left heart → consider pre-capillary PH or group 2 PH with exercise, and right-heart catheterisation [8,180].
Pitfalls & mimics
PitfallE/e′ is not valid in significant mitral annular calcification, mitral stenosis, prosthetic mitral valves, moderate or worse MR, LBBB or paced rhythm, and constriction (annulus paradoxus) [2,32].
- Atrial fibrillation: use septal E/e′ >11, the E-velocity deceleration time, and average over multiple beats [2].
- Obesity degrades windows and lowers natriuretic peptides. A low peptide does not exclude HFpEF in obesity [101].
- Athlete's heart and age: e′ falls with age, so use age-appropriate cut-offs.
- Mimics: constriction (septal bounce, e′ preserved), high-output states (anaemia, thyroid, AV fistula, liver disease), PH, COPD, deconditioning [57,100,201].
- Grade by the algorithm. A single abnormal index does not make HFpEF.