HFpEF mimics
Non-cardiac and cardiac conditions that cause dyspnoea or oedema with a preserved EF, with the clues and the work-up each needs (2026 ACC HFpEF pathway, Table 2 and section 4.4). HFpEF is a diagnosis of exclusion.
With dyspnoea or oedema and EF ≥50%: apply the Universal Definition; first ask whether a non-cardiac entity explains the symptoms (pulmonary disease, kidney disease, high-output states, obesity, frailty); then whether a specific cardiac mimic needs its own work-up (valvular, pericardial, infiltrative or restrictive myocardial disease, ischaemic heart disease); then identify comorbidities that need treatment. HFpEF is a diagnosis of exclusion.
What does this patient have? Tap everything that applies.
Select findings to see the mimics they point to
All 13 mimics in the pathway (Table 2)
- Pulmonary disease (COPD, asthma, interstitial lung disease, pulmonary hypertension) — Pulmonary function tests, chest radiography or CT, V/Q scan or CT pulmonary angiography if thromboembolism is suspected, cardiopulmonary exercise testing, right heart catheterization.
- Kidney disease — Kidney function panel; clinical and ultrasound-based volume assessment; often both HF and kidney disease need treatment.
- High-output states (liver disease, anaemia, hyperthyroidism, AV fistula, systemic inflammation) — CBC, TSH, liver function tests and imaging, inflammatory markers, echocardiography, right heart catheterization.
- Obesity — Cardiopulmonary exercise testing, right heart catheterization, functional assessment.
- Frailty or deconditioning — Clinical evaluation, frailty scales, laboratory evaluation (chemistries, CBC, TSH), exercise capacity including cardiopulmonary exercise testing, right heart catheterization.
- Valvular heart disease (aortic stenosis, mitral regurgitation, mitral stenosis) — Transthoracic echocardiography with Doppler; significant valve disease often needs surgical or transcatheter treatment rather than HFpEF drugs.
- Pericardial constriction — Echocardiography with Doppler; right and left heart catheterization for ventricular interdependence; CMR or CT.
- Ischaemic heart disease (including microvascular angina) — Stress imaging, coronary angiography, coronary functional assessment.
- Cardiac amyloidosis — Monoclonal protein screen (serum and urine immunofixation, serum free light chains); bone-avid scintigraphy read with a negative monoclonal screen; endomyocardial biopsy if the screen is positive; TTR genetic testing.
- Hypertrophic cardiomyopathy — CMR if the echocardiogram leaves doubt; genetic testing.
- Cardiac sarcoidosis — CMR, FDG-PET, tissue biopsy (cardiac or extracardiac).
- Haemochromatosis — Ferritin and transferrin saturation, HFE genetic testing, CMR with T2* imaging.
- Fabry disease — Serum alpha-galactosidase level (in men), GLA genetic testing, biopsy of affected tissue.
Dyspnoea: cardiac, pulmonary or other (anaemia, neuromuscular, deconditioning, obesity, anxiety). Oedema: raised capillary hydrostatic pressure (cardiac, cirrhosis, kidney disease, venous disease, portal hypertension, pregnancy, drugs) or low oncotic pressure (malnutrition, cirrhosis, malabsorption, nephrotic syndrome).