Two-Step Approach Cuts HFpEF Diagnostic Complexity
Assessing left atrial volume and natriuretic peptides (LA/NP) can identify heart failure with preserved ejection fraction (HFpEF) with an 88% specificity and 97% positive predictive value. The strategy reduces the need for additional diagnostics by decreasing intermediate Heart Failure Association pre-test assessment, echocardiography & natriuretic peptide, functional testing, final etiology (HFA-PEFF) or H₂FPEF (Heavy, two or more hypertensive drugs, atrial fibrillation, pulmonary hypertension, elder age > 60 years, elevated filling pressures) algorithm scores by 27%-56%.
METHODOLOGY:
Researchers developed the diagnostic approach to rule in HFpEF using LA indexed for height 2 (LAViH 2 ; cut-off above 35.5 mL/m 2 in sinus rhythm or above 38.6 mL/m 2 in atrial fibrillation) and natriuretic peptides (as per the HFA-PEFF major criterion) with data from 443 patients with suspected HFpEF and validated in two independent cohorts.
(LAViH ; cut-off above 35.5 mL/m in sinus rhythm or above 38.6 mL/m in atrial fibrillation) and natriuretic peptides (as per the HFA-PEFF major criterion) with data from 443 patients with suspected HFpEF and validated in two independent cohorts. End-systolic LA was manually traced in echocardiographic apical four- and two-chamber views and indexed for both body surface area and height 2 , with height 2 -indexed values showing better diagnostic performance in patients with obesity.
, with height -indexed values showing better diagnostic performance in patients with obesity. Researchers developed the simplified approach by determining abnormal values for each measure of LA based on the highest value in control individuals, stratified by sinus rhythm/atrial fibrillation, and using elevated natriuretic peptides based on the HFA-PEFF major criterion.
TAKEAWAY:
The LA/NP approach identified 60% of HFpEF patients with an 88% specificity and a 97% positive predictive value in the derivation cohort, with similar results in the validation cohorts (76%-80% specificity, 92%-97% positive predictive value).
The validation cohorts confirmed the LA/NP approach, with a 21%-57% reduction in intermediate scores, demonstrating consistent diagnostic accuracy across different clinical HFpEF profiles.
Replacing LAViH2 with LA reservoir strain showed comparable results, suggesting flexibility in the echocardiographic parameters that can be used in this simplified diagnostic approach.
IN PRACTICE:
'Using the LA/NP approach as a first step in patients suspected for HfpEF before using the HFA-PEFF or H 2 FPEF algorithm as a second step may substantially reduce the need for additional diagnostics to diagnose HfpEF,' the researchers wrote.
SOURCE:
The study was led by Jerremy Weerts, MSc, MD, of Maastricht University Medical Center in Maastricht, the Netherlands. It was published online in European Journal of Heart Failure and presented at the Heart Failure Association of the European Society of Cardiology (HFA-ESC) 2025 meeting.
LIMITATIONS:
The analyses were performed retrospectively in three independent, prospective cohorts from university hospitals, each with a high prevalence of diagnosed HFpEF, which may affect the performance of the LA/NP approach in less selected populations. The use of different natriuretic peptide assays across cohorts limited the derivation of new cut-off values for the LA/NP approach. Right heart catheterization was not performed in all patients, although this reflects daily clinical practice and aligns with large clinical trials in HFpEF.
DISCLOSURES:
Weerts reported receiving grants from Corvia Medical, CSL Vifor, and Boehringer Ingelheim, unrelated to the submitted work. The study was supported by the Dutch Heart Foundation (grant numbers CVON2017-21-SHE PREDICTS HF and CVON2015-10-Early HFpEF) and the Health Foundation Limburg. Additional disclosures are noted in the original article.
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