Sharpen your HF diagnostic instincts

Timely diagnosis and targeted therapy can significantly improve outcomes for patients with heart failure (HF). Early natriuretic peptide testing is essential, especially in patients with atrial fibrillation (AF), hypertension, or unexplained breathlessness.

Prof. Burkert Pieske (Rostock University Medical Centre, Germany) outlined 6 patient profiles to demonstrate the importance of timely diagnosis and targeted therapy [1]. “We must listen differently, ask deeper questions, and respond faster,” he said. The message was clear: clinicians must look beyond the obvious and educate their peers to identify and manage these patients before deterioration occurs. “We now know how to treat patients with HF with preserved ejection fraction (HFpEF), but the challenge is recognising them early enough to intervene,” he explained.

One particularly compelling example came from Prof. Pieske’s own family. “This is my father,” he shared as patient profile. “He told us he was fine, but only on deeper questioning did we learn he had stopped gardening because it became too exhausting. He had longstanding hypertension, permanent AF, and chronic venous insufficiency.” A natriuretic peptide test revealed an NT-proBNP level of 1,000 pg/mL, confirming HF. “He was one of millions who would go undiagnosed if we didn’t insist on testing,” Prof. Pieske said.

Permanent AF in elderly hypertensive patients should trigger strong diagnostic suspicion. “If your patient has permanent AF and a reasonably controlled heart rate, they most likely have HFpEF,” Prof. Pieske said, citing data where 98% of patients with persistent AF and breathlessness were confirmed to have HFpEF through invasive exercise testing [2,3].

Prof. Pieske also touched upon biomarker-based urgency. “If the NT-proBNP level is above 2,000 pg/mL, don’t wait; 1 in 7 of these patients will be hospitalised within 2 months. These people can’t afford a 3-month wait for workup.”

He stressed the importance of recognising patients who may benefit from emerging phenotype-specific therapies. These include individuals with obesity-related HFpEF, which he claimed is “now a treatable condition with evidence-based drugs that improve weight, inflammation, and quality-of-life,” as well as those with obstructive hypertrophic cardiomyopathy, ATTR amyloidosis, and cardiac sarcoidosis.

“We’ve moved from saying ‘there’s nothing we can do’ to choosing how best to treat and monitor these patients,” he said, encouraging cardiologists to embrace newer therapies while reinforcing the fundamentals: early suspicion, NT-proBNP testing, and comprehensive patient profiling.

“This is not just about symptoms,” Prof. Pieske concluded. “It’s about refining our clinical instincts, identifying early warning signs, and intervening proactively. That’s how we improve HF outcomes.”

1. Pieske B, et al. Decoding HFpEF: modern approaches to diagnosis and management. Session, HFpEF: modern approaches to diagnosis and management. Heart Failure 2025, 17 May, Belgrade, Serbia.
2. Reddy YNV, et al. Circulation. 2018;138(9):861-870.
3. Reddy YNV, et al. J Am Coll Cardiol. 2020;76(9):1051-1064.

Medical writing support was provided by Dr Rachel Giles.

 

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Posted on 24 June 202526 June 2025