An approach to the older patient with a suspicion of HFpEF

It is not uncommon to see older patients who have dyspnea limiting exercise tolerance and a non-diagnostic H2FPEF score, but with an estimated probability of HFpEF of 55-75%. These patients often have dependent edema or hypertension. Frequently we, and the patients themselves, believe their symptoms are due to age, obesity, and deconditioning; however, recent data is suggesting the presence of HFpEF. Even without HFpEF, they are at high risk of developing it over time. There is reluctance in proceeding with a hemodynamic stress test, as it is not readily available and invasive. Both dyspnea on exertion and dependent peripheral edema are sensitive but not specific for HFpEF. Treatment with diuretics does decrease the incidence and recurrence of heart failure in patients with Stage B or C HFpEF. We treat patients with increased LDL cholesterol based on the risk of development of coronary artery disease. Using this same logic, patients with suspected but not proven HFpEF could benefit from the use of mild diuretics targeting peripheral edema or hypertension and ultimately targeting HFpEF or its development.