Should an ischemic evaluation be considered in the diagnostic work-up for new-onset diastolic heart failure/HFpEF in patients without clear anginal symptoms?

The ischemic phenotype is a well-recognized class among HFpEF patients. For men, this usually manifests as macrovascular disease with epicardial CAD, and for females, the more common manifestation is microvascular disease with CMD. Therefore, ischemic evaluation should be considered as part of the w...

Yes, an ischemia eval should be performed. I prefer CT coronary angiography over SPECT imaging, as there are too many false positives and false negatives. For patients with angina or regional wall motion abnormalities, invasive coronary angiography is my first choice.

Yes. Evaluation for ischemia is an important step. Diastolic dysfunction precedes systolic dysfunction in the spectrum of ischemia and occurs even prior to anginal symptom development (albeit, SOB can be considered an anginal equivalent).