Response to Comments on the Article: Heart Failure with Preserved Ejection Fraction in the Indian Context

Dear Editor, This is with reference to the letter relating to our review article, Heart failure with preserved ejection fraction (HFpEF) in the Indian context, published in the journal.[1] Labeling HFpEF as a phenotype and not a clinical diagnosis in a patient with unexplained dyspnea is erroneous. The 2022 AHA/ACC/HFSA Guideline has classified heart failure (HF) in stages according to left ventricular ejection fraction (LVEF), along with markers of elevated left ventricular (LV) filling pressure (e.g., elevated natriuretic peptides and noninvasive or invasive hemodynamic measurements, either spontaneous or provoked).[2] The watershed is the LVEF of 50% (>50% for HFpEF vs. <50% for HF with mildly reduced ejection fraction and HF with reduced ejection fraction) for classification and intervention. We used the same criteria.[1] Two-thirds of patients with HFpEF present with dyspnea, and physical examination, chest radiographic, echocardiographic, or invasive hemodynamic evidence of HF of overt congestion and volume overload at rest, while one-third present with unexplained dyspnea on exertion and do not have clear physical, radiographic, or echocardiographic signs of HF.[3] These patients have elevated atrial pressures with exercise as measured with Doppler echocardiography or invasive hemodynamic stress testing.[3] In the case vignette, the provisional clinical diagnosis of HF was appropriate based on dyspnea on exertion, progressive orthopnea of 2 days’ duration with moderate pedal edema, apical fourth heart sound, and bedside echocardiography, suggesting normal LVEF and Grade 1 diastolic dysfunction. We agree with the correspondents that an LV volume index, left atrial (LA) volume index, and a more detailed Doppler study would have been ideal. However, in this vignette, a normal LV dimension, absence of ECG or echocardiography confirmed hypertrophy, and marginally increased LA dimension points against a hypertrophy-based diastolic dysfunction and therefore would be typical of early presentation of HFpEF. Table 1 in our original publication in this Journal consists of key diagnostic criteria according to various guidelines.[4,5] These diagnostic criteria have not changed in the recent update.[6] We have highlighted additional laboratory (invasive or noninvasive markers) and scoring systems [Tables 2 and 4] to define staging and classification based on clinical evidence outcomes of therapeutic interventions.[1] The therapeutic interventions (medicines or devices) have also changed and are presented in Figures 4-6 and discussed. Our strategy for the treatment of HFpEF is identical to the recent guideline-directed medical therapies[4–6] and summarized in Table 7 and Figure 7. Thus, the present review is summary of a complex topic and should be clinically relevant for a busy physician to understand HFpEF, its diagnostic criteria, and an evidence-informed guidelines-based therapeutic strategy. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.