A 72-year-old woman from Mumbai with a 10-year history of hypertension (on atenolol 50 mg daily) presents with progressive dyspnea, fatigue, and ankle edema for 6 weeks. She denies chest pain or palpitations. On examination: BP 156/94 mmHg, HR 78/min regular, JVP normal, no peripheral edema, lungs clear to auscultation bilaterally, S4 gallop audible. Chest X-ray shows mild cardiomegaly with normal pulmonary vasculature. Echocardiography reveals LVEF 52%, concentric LV hypertrophy, grade 2 diastolic dysfunction, and normal mitral inflow. NT-proBNP is 380 pg/mL. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis This patient presents with **HFpEF (Heart Failure with Preserved Ejection Fraction)** secondary to chronic hypertension. ### Diagnostic Criteria Met | Feature | Finding | Significance | |---|---|---| | **LVEF** | 52% (≥50%) | Preserved ejection fraction | | **LV Structure** | Concentric hypertrophy | Hallmark of hypertensive remodeling | | **Diastolic Function** | Grade 2 dysfunction | Impaired relaxation + elevated filling pressures | | **Clinical Symptoms** | Dyspnea, fatigue, edema | HF symptoms despite normal systolic function | | **NT-proBNP** | 380 pg/mL (borderline elevated) | Supports HF diagnosis (>125 pg/mL abnormal) | | **CXR** | Cardiomegaly, clear lungs | Diastolic HF pattern (no pulmonary edema) | | **Risk Factor** | 10-year hypertension | Primary driver of HFpEF | **Key Point:** HFpEF is defined by the triad of: 1. HF symptoms and signs 2. LVEF ≥50% 3. Evidence of diastolic dysfunction (impaired relaxation, elevated filling pressures) ## Pathophysiology of Hypertensive HFpEF ```mermaid flowchart TD A["Chronic Hypertension"]:::outcome --> B["Increased LV Afterload"]:::action B --> C["Concentric LV Hypertrophy"]:::outcome C --> D["Impaired Relaxation<br/>Increased Stiffness"]:::action D --> E["Elevated LV Filling Pressures"]:::outcome E --> F["Pulmonary Venous Congestion"]:::action F --> G["Dyspnea, Orthopnea, PND"]:::outcome C --> H["Reduced Compliance"]:::action H --> E ``` **High-Yield:** The key distinguishing feature is **concentric LV hypertrophy** (not eccentric as in systolic HF or dilated cardiomyopathy). This is pathognomonic for chronic pressure overload (hypertension, aortic stenosis). ## Why HFpEF, Not Systolic HF? - **LVEF 52%** is normal (systolic HF requires LVEF ≤40%) - **Concentric hypertrophy** indicates pressure overload, not primary myocardial dysfunction - **Grade 2 diastolic dysfunction** is the functional abnormality, not systolic impairment - **Clear lungs on CXR** suggest diastolic HF pattern (elevated LV end-diastolic pressure without pulmonary edema) ## Management Principles for HFpEF **Key Point:** Unlike HFrEF, there is NO mortality-reducing pharmacotherapy proven for HFpEF. Management is symptom-directed: 1. **Blood pressure control** (target <130/80 mmHg) — reduces LV hypertrophy and improves diastolic function 2. **Diuretics** — for symptom relief (dyspnea, edema) 3. **Beta-blockers / rate control** — slow HR to allow longer diastolic filling time 4. **ACE-I / ARB** — may regress LV hypertrophy (evidence mixed) 5. **Avoid tachycardia** — reduces diastolic filling time **Clinical Pearl:** The patient is on atenolol (beta-blocker), which is appropriate for rate control and BP management in HFpEF. However, BP control is suboptimal (156/94 mmHg); intensification of antihypertensive therapy is needed. ## Why Each Distractor is Wrong 1. **Option 0 (Acute decompensated systolic HF):** LVEF is 52%, which is normal. Systolic HF requires LVEF ≤40%. The patient has preserved systolic function; the problem is diastolic dysfunction, not systolic impairment. Acute decompensation typically presents with pulmonary edema on CXR; this patient has clear lungs. 2. **Option 2 (Restrictive cardiomyopathy):** Restrictive cardiomyopathy presents with severe diastolic dysfunction (grade 3–4), marked biatrial enlargement, and normal or only mildly reduced LVEF. However, restrictive cardiomyopathy is a primary myocardial disease (amyloidosis, sarcoidosis, hemochromatosis), not secondary to hypertension. The clinical context (chronic hypertension, concentric hypertrophy) points to hypertensive heart disease, not restrictive cardiomyopathy. Additionally, the diastolic dysfunction is only grade 2, not severe. 3. **Option 3 (Cor pulmonale):** Cor pulmonale is right heart dysfunction secondary to chronic lung disease (COPD, ILD, pulmonary hypertension). The patient has clear lungs on CXR and no history of lung disease. LV hypertrophy and diastolic dysfunction are not features of cor pulmonale; instead, cor pulmonale presents with RV hypertrophy and right atrial enlargement. The elevated BP and LV-centric findings rule out cor pulmonale. ## Diagnostic Algorithm for HF ```mermaid flowchart TD A["HF Symptoms + Signs"]:::outcome --> B{"LVEF?"}:::decision B -->|"≤40%"| C["HFrEF"]:::outcome B -->|"41–49%"| D["HFmrEF"]:::outcome B -->|"≥50%"| E{"Diastolic Dysfunction?"}:::decision E -->|Yes| F["HFpEF"]:::outcome E -->|No| G["Non-cardiac cause"]:::outcome C --> H["ACE-I, BB, MRA, SGLT2i"]:::action D --> I["Similar to HFrEF"]:::action F --> J["BP control, diuretics,<br/>rate control"]:::action ``` **Mnemonic:** **HFpEF = Hypertension + Preserved EF + Diastolic dysfunction** — the classic triad of diastolic heart failure in the elderly hypertensive patient.