Early diagnosis of heart failure with preserved ejection fraction: From primary care screening to invasive hemodynamic confirmation

Heart failure with preserved ejection fraction (HFpEF) is one of the most common forms of heart failure, and its prevalence is rising. As disease-modifying therapies become available, the accurate identification of early-stage HFpEF has become a major clinical priority. However, many patients with HFpEF are often managed for comorbidities such as hypertension, obesity, or diabetes, without recognizing the presence of HFpEF and targeted heart failure evaluation. In primary care, clinicians should keep HFpEF on the differential diagnosis for patients with unexplained exertional dyspnea, especially in older adults and in those with comorbidities such as obesity and atrial fibrillation. Simple clinical scores have been developed for this setting, including the HFpEF-ABA and BREATH₂ scores. These scoring systems can help clinicians estimate pre-test probabilities, enabling them to identify patients who should be referred to secondary or tertiary specialist centers. Close collaboration between primary care and secondary or tertiary centers is essential for timely diagnosis, treatment, and follow-up. In secondary and tertiary care settings, more detailed multimodality scores, such as H₂FPEF and HFA-PEFF which utilize natriuretic peptide levels and comprehensive echocardiography, are useful to rule in HFpEF. However, these scores have limited sensitivity to rule out HFpEF, particularly in obese patients, in whom natriuretic peptides and diastolic indices may underestimate the severity of left ventricular filling pressure. Patients with an intermediate probability should be evaluated by exercise stress echocardiography, but a substantial proportion of patients with negative or indeterminate test results still meets invasive hemodynamic criteria for HFpEF. This review summarizes current diagnostic strategies for suspected HFpEF and proposes a practical framework that combines validated noninvasive tools with selective use of invasive hemodynamic exercise testing and careful longitudinal follow-up.