Algorithm for diagnosis of heart failure with preserved ejection fraction^[1]

HF: heart failure; LVEF: left ventricular ejection fraction; HFpEF: heart failure with preserved ejection fraction; PCWP: pulmonary capillary wedge pressure.
* Patients with HF have one or more symptom of HF such as dyspnea (such as dyspnea on exertion, paroxysmal noctural dyspnea, or orthopnea) or fatigue. Patients with HF may or may not have a physical sign of HF such as elevated jugular venous pressure, pulmonary rales, or lower extremity edema.
¶ Evaluation of patients with HF includes Doppler transthoracic echocardiography to evaluate LVEF, estimate pulmonary artery systolic pressure, assess left ventricular filling pressure, and assess cause of HF.
Δ Causes of HF with LVEF ≥50% other than HFpEF include a cardiomyopathy (eg, hypertrophic or restrictive cardiomyopathy), significant valve disease (severe stenosis or regurgitation or at least moderate mixed stenosis and regurgitation), pericardial disease (eg, constrictive pericarditis), right HF not associated with HFpEF, and high-output HF. Clinical evaluation including echocardiography is helpful in identifying these conditions. For further details, refer to the discussion of differential diagnosis in the UpToDate content on diagnosis of HFpEF.
◊ Refer to the H₂FPEF score and HFA-PEFF score in the UpToDate content on diagnosis of HFpEF.
§ If the cause of symptoms remains uncertain after echocardiography and evaluation for noncardiac causes, a hemodynamic exercise test is suggested (if not already performed) to determine if HFpEF is present.
¥ During a hemodynamic exercise test, pulmonary artery pressures and PCWP are measured at rest and during exercise with cycle ergometry (in patients with internal jugular venous access) or arm abduction (in those with femoral venous access). Pressures are measured at end-expiration.