A 72-year-old woman from Mumbai with a 5-year history of hypertension and no prior cardiac events presents with progressive dyspnea, fatigue, and ankle edema over 2 months. On examination, BP is 156/92 mmHg, HR 78/min regular, JVP normal, no crackles, but S4 gallop is present. Echocardiography shows LVEF 50%, left ventricular wall thickness 14 mm, and a restrictive mitral inflow pattern. Which of the following is the most likely diagnosis?

Explanation

## Clinical Presentation Analysis **Key Point:** This patient has **HFpEF (heart failure with preserved ejection fraction)** secondary to hypertensive left ventricular hypertrophy. ## Diagnostic Criteria for HFpEF | Feature | This Patient | Significance | |---|---|---| | **LVEF** | 50% (≥50%) | Preserved systolic function | | **LV wall thickness** | 14 mm | Concentric LVH from chronic hypertension | | **S4 gallop** | Present | Reflects stiff, non-compliant LV | | **Restrictive mitral pattern** | Present | Impaired LV relaxation and filling | | **JVP** | Normal | No acute volume overload | | **Crackles** | Absent | No pulmonary edema (yet) | | **Risk factor** | Hypertension × 5 years | Primary driver of LVH | ## Pathophysiology of HFpEF 1. **Chronic hypertension** → increased afterload 2. **Concentric LVH** (wall thickness ↑) → reduced LV compliance 3. **Impaired diastolic relaxation** → restrictive filling pattern 4. **Elevated filling pressures** → dyspnea and fatigue despite normal LVEF **Mnemonic: HFpEF = **H**ypertension, **F**ibrosis, **p**reserved **E**F** — remember that HFpEF is driven by diastolic dysfunction, not systolic dysfunction. ## Why This Is NOT Systolic HF - LVEF 50% is **normal** (systolic HF requires LVEF <40%) - No dilated left ventricle - S4 (not S3) — S4 reflects stiff LV; S3 reflects dilated, failing LV ## Why This Is NOT Restrictive Cardiomyopathy **Clinical Pearl:** Restrictive cardiomyopathy (amyloidosis, sarcoidosis) typically presents with: - Severe diastolic dysfunction with **biatrial enlargement** - Often **low voltage on ECG** (amyloidosis) - Normal or mildly reduced LVEF - **No significant LVH** (wall thickness may be normal or only mildly increased) This patient has **concentric LVH** (14 mm wall thickness) with a clear hypertensive history — not restrictive cardiomyopathy. ## Why This Is NOT Mitral Stenosis - Mitral stenosis causes a **restrictive filling pattern** but also produces: - **Atrial fibrillation** (common) - **Elevated JVP** (right heart strain) - **Loud S1** and **opening snap** on auscultation - **Rheumatic history** (in endemic areas) - This patient has normal JVP and a hypertensive history, not rheumatic disease. ## Management of HFpEF **High-Yield:** HFpEF management focuses on: 1. **Blood pressure control** (ACE-I/ARB, beta-blockers, CCBs) 2. **Rate control** (if AF develops) 3. **Diuretics** for congestion 4. **No proven mortality benefit** from ACE-I/ARB (unlike HFrEF) 5. **SGLT2 inhibitors** (emerging evidence: dapagliflozin, empagliflozin)