Heart failure with preserved ejection fraction (HFpEF) now accounts for more than half of all heart failure cases globally, yet it remains significantly underdiagnosed, particularly in primary care settings.
A review published in the Journal of Cardiology highlights the diagnostic challenges associated with the condition and proposes a structured framework combining noninvasive tools with selective use of invasive testing and longitudinal follow-up.
HFpEF is frequently missed in primary care because its early symptoms, most notably exertional dyspnoea, are nonspecific and commonly attributed to comorbidities such as obesity, hypertension, atrial fibrillation, and diabetes.
Standard resting assessments, including natriuretic peptide measurement and echocardiography, often lack sufficient sensitivity, particularly in patients with obesity who tend to present with lower natriuretic peptide levels at rest.
The review authors recommend that primary care clinicians maintain a heightened index of suspicion in older patients with unexplained exertional breathlessness and relevant comorbidities.
Two clinical scoring tools are proposed to support early recognition: the HFpEF-ABA score, which incorporates age, body mass index, and history of atrial fibrillation; and the BREATH2 score, which assesses seven variables, including natriuretic peptide levels, cardiomegaly on chest radiography, coronary artery disease, anaemia, atrial fibrillation, age, and left ventricular voltage on ECG. Neither tool requires echocardiographic parameters, making both practical for primary care use.
In secondary and tertiary settings, validated tools such as the H2FPEF score and the HFA-PEFF algorithm provide additional diagnostic precision, with exercise stress echocardiography recommended as the final noninvasive step. Invasive exercise haemodynamics, using pulmonary arterial wedge pressure thresholds, remains the gold standard for confirming diagnosis when noninvasive results are inconclusive or discordant with clinical suspicion.
Source: Harada T et al. Journal of Cardiology (2026). DOI: 10.1016/j.jjcc.2026.01.014
