The diagnosis and subclassification of heart failure with preserved ejection fraction: a review

The incidence and prevalence of Heart Failure with Preserved Ejection Fraction (HFpEF) continues to rise and has a mortality rate comparable to that of Heart Failure with Reduced Ejection Fraction (HFrEF). Whilst there is general agreement on the diagnostic criteria for HFrEF, the diagnostic criteria for HFpEF vary significantly which has resulted in inconsistent and varying inclusion criteria in clinical trials for this challenging syndrome. The HFpEF population is diverse and heterogeneous and various schemes of subcategorisation have been proposed. Failure of treatment trials to date can be explained, in part, by failure to consider the underlying sub-phenotypes within the HFpEF population. This review discusses the diagnostic uncertainty surrounding HFpEF and details the historical progression in the understanding of diastolic dysfunction and its role in the heart failure syndrome. An analysis of diagnostic criteria and suggested phenotypic subcategorisation is accompanied by a discussion of echocardiographic and invasive haemodynamic criteria. A detailed summary of the varied inclusion criteria and definitions employed in recent clinical trials is provided.