Diagnosis of heart failure with preserved ejection fraction: guidelines and real-world clinical practice
S Azhgaliyeva, V Medovchshikov, N Yeshniyazov, G Aryspayeva, Z H Lepessova, Z H Oralbekova, A Baizhanova, E Suieugaziyeva, M Balabayeva, G Yussupova, Z H Iskakova, D Murzagaliyeva, B Duisenbayev, G Kurmanalina, B ZholdinAbstract
Background
Despite the existence of a formal diagnostic algorithm for heart failure with preserved ejection fraction (HFpEF) recommended by the ESC, its implementation remains a major challenge in clinical practice.Accurate HFpEF diagnosis requires a comprehensive assessment that integrates echocardiographic and biomarker-based criteria. However, real-world data on adherence to these recommendations remain limited.
Purpose
To evaluate the frequency of reporting key diagnostic parameters recommended for HFpEF assessment among patients hospitalized with acute heart failure (AHF).
Methods
This retrospective registry study included 433 patients hospitalized for de novo or chronic AHF across five centers in four regions of West Kazakhstan. Participating centers provided medical records (discharge summaries) covering at least one month of 2024. Data on NT-proBNP measurement and echocardiographic parameters were extracted from discharge summaries.The variables of interest included the frequency of NT-proBNP testing and echocardiographic indicators recommended for HFpEF assessment according to the 2021 ESC Guidelines.
Results
Ischemic HF etiology was identified in 56.8% of patients. The median left ventricular ejection fraction (LVEF) was 40 (31; 46)%. Among the cohort, 13.8% had HFpEF, 32.1% had HFmrEF, and 54.1% had HFrEF. NT-proBNP was measured in 55.4% of patients, with significantly higher testing rates in HFpEF cases (78%) compared with HFrEF (48.1%, p<0.001) and HFmrEF (59.1%, p=0.023). However, 14.5% of medical records lacked a complete echocardiography protocol and contained only a brief narrative summary.LVEF data were available for all patients. Nonetheless, key echocardiographic parameters required for HFpEF assessment – left atrial volume index, relative wall thickness, E/e′ ratio, and resting tricuspid regurgitation velocity – were absent from all records. Pulmonary artery systolic pressure (PASP) was documented in 92.4% of cases, with no significant differences between HF phenotypes. Left ventricular mass index (LVMI) was reported significantly more often in HFpEF cases (81.4%) compared with HFrEF (63.6%, p=0.019), but not compared with HFmrEF (80.3%). The number of evaluated parameters, including NT-proBNP and echocardiographic findings necessary for HFpEF diagnosis, is presented in Figure 1.
Conclusion
This analysis highlights significant gaps in adherence to ESC-recommended diagnostic criteria for HFpEF. The lack of standardized echocardiographic assessment and incomplete NT-proBNP testing may hinder accurate HF phenotyping in clinical practice. A key limitation is that echocardiography is often performed by functional diagnostics specialists rather than clinical cardiologists, and discharge summaries frequently lack a complete echocardiography report. To improve diagnostic quality and standardize patient management, specialized training programs, unified echocardiography protocols, and regular audits should be implemented.Figure 1 For image description, please refer to the figure legend and surrounding text.