Table 1.3. HFpEF diagnosis recommendations.

Recommendations	Class	LE	Comments	Table 2018	Ref.
Natriuretic peptides for HFpEF screening.	I	B	NEW: The wide variation in serum levels of natriuretic peptides in this population and the conditions that modify its accuracy, such as atrial fibrillation and obesity, should be considered.	New	3, 4
Comprehensive echocardiogram for diagnosis confirmation.	I	B	NEW: Echocardiogram with presentation of Doppler indices to estimate pulmonary and diastolic pressures, as well as cardiac mass and volume indices indexed to body surface.	New	4, 5
H2FPF or HFA PEFF diagnostic scores to improve diagnostic accuracy for suspected cases of HFpEF.	IIa	B	NEW: Scores validated using retrospective cohorts.	New	6–8
Assessment of diastolic function during stress by echocardiogram or invasive hemodynamic monitoring in cases of intermediate probability in the H2FPF or HFA PEFF scores.	IIb	B	NEW: Scores validated using retrospective cohorts.	New	9,10
The initial strategy for HFpEF diagnosis is to determine the pretest probability of HF through the use of clinical findings associated with supplementary tests, such as electrocardiograms, chest X-rays, echocardiograms, and natriuretic peptides, if available. When interpreting natriuretic peptide test results, it is important to consider there is a wide range of serum levels in this population and that, in the presence of atrial fibrillation (AF), higher thresholds need to be considered.3,4 If HF is a plausible diagnosis, it is reasonable to apply H2FPEF5,6 and HFA PEFF7 scores (the first with clinical and echocardiography data, the latter with comprehensive echocardiography and natriuretic peptide data), which have been validated in international populations6,8 to determine high, intermediate and low probability. In patients with low probability of HFpEF, the objective pursuit of other etiologies for dyspnea is suggested. In individuals with intermediate probability, recent studies have shown that data on diastolic function during stress may identify patients with abnormal responses, representing a noninvasive (echocardiographic diastolic assessment)9 or invasive (pulmonary artery catheter) diagnostic strategy.10 The scoring systems above require comprehensive echocardiograms; in other words, the examination should provide information on diameters, left atrial volume, flow Doppler, tissue Doppler (septal and/or lateral e’), and, if possible, myocardial strain and strain rate data·5

AF: atrial fibrillation; HF: heart failure; HFpEF: heart failure with preserved ejection fraction