Revisiting the Diagnosis of HFpEF in Acute Dyspnoea: Why Structurally Normal Hearts Rarely Decompensate

Abstract: Heart failure with preserved ejection fraction (HFpEF) is commonly diagnosed in patients with acute dyspnoea. However, both historical trial data and real-world observations suggest that acute decompensation in structurally normal hearts is exceedingly rare. In particular misinterpretation of common diagnostic tools—particularly echocardiographic parameters (e.g., IVC dynamics, sPAP) and natriuretic peptides (e.g., NT-proBNP)—contributes to substantial overdiagnosis. This mini-review argues that the concept of 'pure' HFpEF lacks consistent pathophysiological support and clinical validation and proposes a more physiologically coherent interpretation of imaging and biomarkers is essential to reduce misdiagnosis.