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European Heart Journal Advance Access originally published online on April 11, 2007
European Heart Journal 2007 28(20):2539-2550; doi:10.1093/eurheartj/ehm037
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© The European Society of Cardiology 2007. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology

Walter J. Paulus1,*, Carsten Tschöpe2, John E. Sanderson3, Cesare Rusconi4, Frank A. Flachskampf5, Frank E. Rademakers6, Paolo Marino7, Otto A. Smiseth8, Gilles De Keulenaer9, Adelino F. Leite-Moreira10, Attila Borbély11, István Édes11, Martin Louis Handoko1, Stephane Heymans12, Natalia Pezzali4, Burkert Pieske13, Kenneth Dickstein14, Alan G. Fraser15 and Dirk L. Brutsaert9

1 Laboratory of Physiology, VU University Medical Center, Van der Boechorststraat, 7, 1081 BT, Amsterdam, The Netherlands
2 Charité Universitätskliniken, Campus Benjamin Franklin, Berlin, Germany
3 Keele University, Stoke-on-Trent, UK
4 S.Orsola Hospital, Brescia, Italy
5 University of Erlangen, Germany
6 University of Leuven, Belgium
7 Universita degli Studi del Piemonte Orientale, Novara, Italy
8 Rikshospitalet, Oslo, Norway
9 Middelheim Ziekenhuis, Antwerp, Belgium
10 University of Porto, Portugal
11 Institute of Cardiology UDMHSC, Debrecen, Hungary
12 University Hospital Maastricht, The Netherlands
13 Georg-August-Universität, Göttingen, Germany
14 Stavanger University Hospital, Norway
15 University of Wales College of Medicine, Cardiff, UK

Received 28 November 2006; accepted 23 February 2007; online publish-ahead-of-print 11 April 2007.

* Corresponding author. Tel: +31 20 4448110; fax: +31 20 4448255. E-mail address: wj.paulus{at}vumc.nl

See page 2421 for the editorial comment on this article (doi:10.1093/eurheartj/ehm412)

Diastolic heart failure (DHF) currently accounts for more than 50% of all heart failure patients. DHF is also referred to as heart failure with normal left ventricular (LV) ejection fraction (HFNEF) to indicate that HFNEF could be a precursor of heart failure with reduced LVEF. Because of improved cardiac imaging and because of widespread clinical use of plasma levels of natriuretic peptides, diagnostic criteria for HFNEF needed to be updated. The diagnosis of HFNEF requires the following conditions to be satisfied: (i) signs or symptoms of heart failure; (ii) normal or mildly abnormal systolic LV function; (iii) evidence of diastolic LV dysfunction. Normal or mildly abnormal systolic LV function implies both an LVEF > 50% and an LV end-diastolic volume index (LVEDVI) <97 mL/m2. Diagnostic evidence of diastolic LV dysfunction can be obtained invasively (LV end-diastolic pressure >16 mmHg or mean pulmonary capillary wedge pressure >12 mmHg) or non-invasively by tissue Doppler (TD) (E/E' > 15). If TD yields an E/E' ratio suggestive of diastolic LV dysfunction (15 > E/E' > 8), additional non-invasive investigations are required for diagnostic evidence of diastolic LV dysfunction. These can consist of blood flow Doppler of mitral valve or pulmonary veins, echo measures of LV mass index or left atrial volume index, electrocardiographic evidence of atrial fibrillation, or plasma levels of natriuretic peptides. If plasma levels of natriuretic peptides are elevated, diagnostic evidence of diastolic LV dysfunction also requires additional non-invasive investigations such as TD, blood flow Doppler of mitral valve or pulmonary veins, echo measures of LV mass index or left atrial volume index, or electrocardiographic evidence of atrial fibrillation. A similar strategy with focus on a high negative predictive value of successive investigations is proposed for the exclusion of HFNEF in patients with breathlessness and no signs of congestion.

The updated strategies for the diagnosis and exclusion of HFNEF are useful not only for individual patient management but also for patient recruitment in future clinical trials exploring therapies for HFNEF.

Key Words: Heart failure • Diastole • Tissue doppler • Natriuretic peptides • Ejection fraction


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