Amil Shah, MD: Echocardiography for the Diagnosis of HFpEF

Amil Shah, MD: Transthoracic echocardiography is usually the first-line imaging test when clinicians have a suspicion of heart failure with preserved ejection fraction. I think kind of the most salient things that came out in looking into this topic is threefold.

First, that the classic structural changes that we tend to associate with heart failure with preserved ejection fraction, while indicative of that state, are actually not present in the majority of those patients. So left ventricular hypertrophy, we can't use as a screen to say someone does or doesn't have this condition. The second is that when we think about using diastolic assessments by echo - which is the way we most commonly assess diastolic dysfunction in our patients - it's very important to interpret the numbers we get in the context of the age of the patient. And if we do that appropriately, I think the utility and prognostic value of those measures increase substantially. Then the third is that, even though we call it heart failure with preserved ejection fraction, many of these patients actually have abnormalities of systolic function and if we can recognize those it may help us identify the people who actually have this syndrome versus those who are short of breath for other causes and tell us more about how they're going to do in the future.

I think the major clinical implications are that, first of all, there are things that we can learn on the echo in someone that we have a concern for potential HFpEF, beyond just that the ejection fraction is normal and that the patient doesn't have severe valvular disease. But, the second is that a lot of the things that are informative are somewhat subtle. So things like mild increases in wall thickness, these abnormalities in Doppler patterns for diastolic function, and even the systolic abnormalities that we don't always routinely measure. So for the clinician who really has a concern, it may not be enough to just get an echo and read the report. There may be utilities for actually going to the person who interprets the study, and looking at the study in the context - specifically of that clinical question - because a lot of these abnormalities can otherwise be subtle on an echo.