Integration of exercise evaluation into the algorithm for evaluation of patients with suspected heart failure with preserved ejection fraction

Approximately half of all patients with heart failure (HF) have a preserved left ventricular ejection fraction (HFPEF) and the prevalence of this form of HF is increasing. Although dyspnoea on exertion and diminished functional capacity is the key symptom of patients with HFPEF, current diagnostic criteria focus on resting indices of ventricular function. Specifically, current proposed criteria for the diagnosis of HFPEF, include clinical signs of HF; normal left ventricular systolic function; and evidence of abnormal diastolic performance and/or altered natriuretic peptides. By contrast, recent studies demonstrate that the key pathophysiologic features of HFPEF may not be evident at rest, and can only be detected during exertion. This review addresses the potential role of exercise testing using invasive haemodynamic or echocardiographic assessment in patients with suspected HFPEF in which current diagnostic criteria are not met.