Diagnostic testing in patients with suspected HFpEF

Harriette Van Spall, MD, MPH, is an associate professor in the Division of Cardiology at McMaster University.

Which diagnostic testing should be performed in patients with suspected heart failure with preserved ejection fraction (HFpEF)?

The diagnosis of HFpEF can be a challenge. In addition to the history and physical examination, electrocardiography is routinely performed to assess for abnormal rhythm or conduction or evidence of myocardial infarction. Chest x-ray can be very useful in assessing for interstitial or pulmonary edema.

Echocardiography can assess for structural or functional abnormalities. One must rule out shunts and valvular pathology that may present similarly to heart failure (HF). It can also help assess for underlying cardiac etiologies of the presentation, including mimickers of HFpEF. Cardiac amyloidosis/sarcoidosis, hemochromatosis, as well as other conditions can mimic HFpEF and should be excluded.

There are additional diagnostic modalities for these conditions. Laboratory investigations such as cardiac biomarkers, the assessment of serum protein electrophoresis (SPEP) or urine protein electrophoresis (UPEP), diagnostic modalities such as technetium-pyrophosphate scans, cardiac magnetic resonance imaging (MRI), cardiac positron emission tomography (PET) can be very useful in assessing for cardiac structural abnormalities and also in ruling out those HFpEF mimickers.

So the diagnosis could be made based on history and physical exam, but then one must accompany that with laboratory investigations, electrocardiography, echocardiography, and then additional modalities based on clinical suspicion.