Screening for Undiagnosed Heart Failure: A Viewpoint.

The syndrome of heart failure (HF) is characterized by a triad of (1) signs and symptoms, (2) cardiac alterations, and (3) natriuretic peptide elevation. Patients who exhibit alterations of cardiac structure or function without overt signs or symptoms of HF are staged as having "pre-HF." However, many people with undiagnosed HF walk little and do not exercise; thus, they may be classified as having asymptomatic "pre-HF" simply because they never exercise enough to feel breathless. Moreover, many patients have comorbidities such as chronic obstructive pulmonary disease or obesity and the physical limitations may be attributed to the comorbidities rather than to HF. Such comorbidities may also influence natriuretic peptide measurements. The potential implications of an HF misdiagnosis are that many patients may remain undertreated. This is illustrated with data from the HOMAGE (Heart Omics in AGEing) study, which included asymptomatic people with mild natriuretic peptide elevation. When comparing patient characteristics, HOMAGE participants were similar to those of ALDO-DHF (Effect of Spironolactone on Diastolic Function and Exercise Capacity in Patients with Heart Failure with Preserved Ejection Fraction) who were classified as symptomatic patients with HF. Given the confluence of HF with several cardiac-renal and metabolic conditions, we propose a simplified, pragmatic, and inclusive approach for early HF diagnosis and treatment.