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Diastolic Stress Testing for HFpEF — EECC MCQ

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HardCardiac ImagingDiastolic Stress Testing for HFpEFEECC

A 65-year-old man with normal LVEF presents with exertional dyspnoea. Echocardiography shows E/e' of 10 and LAVi of 30 mL/m². Natriuretic peptides are borderline (NT-proBNP 180 pg/mL). The 2016 ASE/EACVI diastolic function algorithm is indeterminate. What additional investigation can help diagnose HFpEF?

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Correct answer: A — Diastolic stress testing (exercise echocardiography measuring E/e' at peak exercise) — an E/e' ≥15 at peak exercise unmasks elevated filling pressures not apparent at rest and supports the HFpEF diagnosis

HFpEF diagnosis is challenging when resting parameters are indeterminate. The HFA-PEFF diagnostic algorithm (ESC 2019 consensus) recommends diastolic stress testing as the next step: during exercise echocardiography, measurement of E/e' at peak exercise can unmask elevated filling pressures. An E/e' ≥15 at peak exercise (or septal e' velocity that fails to increase normally) strongly supports the HFpEF diagnosis. If echocardiographic stress testing remains indeterminate, invasive exercise RHC (measuring PCWP at rest and exercise — PCWP >25 mmHg at exercise confirms HFpEF) is the gold standard. The HFA-PEFF score integrates: echocardiographic parameters, natriuretic peptides, and clinical features to generate a probability of HFpEF, guiding the need for further testing.

Reference: ESC (2023): HF Guidelines; HFA-PEFF Algorithm