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Assessment/Diagnosis
➤ Screening: Key Screening Recommendations 2022 AHA/ACC/
HFSA Guideline
• Stage A (at risk): Screen individuals with hypertension, T2DM,
obesity, or cardiovascular disease using brain natriuretic peptide
(BNP) or N-terminal pro–B-type natriuretic peptide (NT-proBNP)
and echocardiography to detect early structural changes (e.g., left
ventricular hypertrophy, elevated f illing pressures).
• Stage B (pre-HF): Recommend annual biomarker testing
(BNP ≥35 pg/mL or NT-proBNP ≥125 pg/mL) and imaging for
asymptomatic patients with structural heart disease or risk factors.
▶ For high-risk populations, adults with a BMI ≥30 kg/m² or a
waist-to-height ratio ≥0.5 should undergo screening for HF that
includes annual blood pressure and lipid assessments, fasting
glucose testing, and HbA1c testing. Measurement of natriuretic
peptides (BNP/NT-proBNP) is advised using obesity-adjusted
thresholds, recognizing that elevated BMI is associated with
lower circulating natriuretic peptide levels even in established
HF, and echocardiography should be performed to evaluate left
ventricular mass index, E/e' ratio (values >9 indicating diastolic
dysfunction), and left atrial strain. The Heavy Hypertensive Atrial
Fibrillation Pulmonary Hypertension Elderly Filling Pressure
(H2FPEF) score (calculation based on BMI, BP meds, atrial
f ibrillation, pulmonary artery pressure, age, and mitral valve
flow [E/e']), helps estimate HFpEF probability. Notably, the
European Society of Cardiology Guidelines on Hypertrophic
Cardiomyopathy recommend prioritizing the waist-to- height
ratio over BMI as a superior predictor of HF risk.
➤ Diagnosis Criteria
• HFpEF is def ined by clinical symptoms or signs of HF in the
presence of a left ventricular ejection f raction (LVEF) ≥50%, with
supporting evidence of elevated left ventricular f illing pressures
(such as E/e'>9, left atrial volume index >34 mL/m², or a pulmonary
capillary wedge pressure ≥25 mm Hg on invasive exercise testing)
and a high diagnostic probability indicated by an HFA-PEFF score
≥5 or H2FPEF score ≥6. In contrast, HF with reduced ejection
f raction (HFrEF) is characterized by HF symptoms or signs with
LVEF ≤40%, f requently arising f rom advanced obesity-related
cardiomyopathy. Risk stratif ication in individuals with obesity
may be further ref ined by elevated biomarkers, including high-
sensitivity C-reactive protein (>2 mg/L) or soluble suppression of
tumorigenicity 2 (ST2).
