A 72-year-old woman from Mumbai with a 10-year history of hypertension (on atenolol 50 mg daily) and diabetes presents with progressive dyspnea, fatigue, and ankle edema for 2 months. She denies chest pain or orthopnea. On examination, BP 156/88 mmHg, HR 72/min regular, JVP normal, no crackles, but 2+ bilateral ankle edema and hepatomegaly. Echocardiography shows LVEF 52%, concentric left ventricular hypertrophy, and diastolic dysfunction (E/e' ratio 15). NT-proBNP 450 pg/mL. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: HFpEF (Heart Failure with Preserved Ejection Fraction) ## Key Diagnostic Criteria | Feature | Finding | Interpretation | |---------|---------|----------------| | **LVEF** | 52% | Preserved (≥50%) | | **Diastolic dysfunction** | E/e' ratio 15 | Elevated; indicates impaired relaxation | | **LV morphology** | Concentric hypertrophy | Hallmark of hypertensive remodeling | | **Symptoms** | Dyspnea, edema, fatigue | Consistent with HF; no orthopnea (milder) | | **NT-proBNP** | 450 pg/mL | Elevated (>125 pg/mL suggests HF) | | **Etiology** | Hypertension + diabetes | Primary risk factors for HFpEF | **High-Yield:** HFpEF accounts for ~50% of all heart failure cases, particularly in elderly women with hypertension and diabetes. ## Pathophysiology of HFpEF 1. **Chronic hypertension** → increased afterload → concentric LV hypertrophy 2. **Myocardial fibrosis** → impaired diastolic relaxation (E/e' ↑) 3. **Reduced LV compliance** → elevated filling pressures despite normal EF 4. **Pulmonary and systemic congestion** → dyspnea, edema **Key Point:** HFpEF is a **diastolic dysfunction** problem, not systolic. The ventricle contracts normally but relaxes poorly. ## Diagnostic Algorithm for HFpEF ```mermaid flowchart TD A[Dyspnea + edema<br/>+ elevated BNP]:::outcome --> B{LVEF?}:::decision B -->|≤40%| C[HFrEF]:::outcome B -->|41-49%| D[HFmrEF]:::outcome B -->|≥50%| E{Diastolic dysfunction?}:::decision E -->|Yes<br/>E/e' >14<br/>or LA enlargement| F[HFpEF]:::outcome E -->|No| G[Rule out other causes:<br/>PE, restrictive CM,<br/>pericarditis]:::action F --> H[Treat HTN, DM,<br/>diuretics, SGLT2i]:::action ``` ## Why Not the Other Options? **Option 0 (Acute decompensated systolic HF):** - LVEF is 52%, which is preserved, not reduced - "Systolic" HF by definition requires EF ≤40% - This is a fundamental misclassification **Option 2 (Restrictive cardiomyopathy):** - Restrictive CM typically presents with severe diastolic dysfunction and markedly elevated filling pressures - Concentric hypertrophy from hypertension is NOT restrictive CM - Restrictive CM is rare and usually has a specific etiology (amyloidosis, sarcoidosis, hemochromatosis) - No mention of these etiologies in the case **Option 3 (Pulmonary hypertension from COPD):** - No respiratory history or COPD mentioned - Hepatomegaly and ankle edema suggest right heart failure secondary to left heart disease, not primary PH - NT-proBNP elevation is more consistent with HF than isolated PH ## Management of HFpEF **Key Point:** Unlike HFrEF, there is no single disease-modifying agent proven to reduce mortality in HFpEF. Management is symptom-focused: 1. **Blood pressure control** — ACE-I/ARB or thiazide diuretic 2. **Diuretics** — for congestion (dyspnea, edema) 3. **SGLT2 inhibitors** — emerging evidence (DELIVER, EMPEROR-Preserved trials) 4. **Rate control** — if AF present 5. **Treat comorbidities** — diabetes, CKD, obesity **Clinical Pearl:** The patient is already on atenolol (beta-blocker), which provides rate control and BP reduction. Consider adding an ACE-I or ARB if not contraindicated, and optimize diuretic dosing for edema. SGLT2 inhibitors (empagliflozin, dapagliflozin) are increasingly recommended in HFpEF.