A 72-year-old woman from Mumbai with a 10-year history of hypertension and diabetes presents with progressive dyspnea, fatigue, and ankle swelling for 6 weeks. On examination: BP 145/92 mmHg, HR 88/min regular, JVP 6 cm, no S3 gallop, lungs clear to auscultation bilaterally. Echocardiography shows LVEF 52%, LV wall thickness 14 mm, LA enlargement, and restrictive mitral inflow pattern (E/A ratio 2.2, E/e' ratio 14). Which of the following is the most likely diagnosis?
A. Acute decompensated heart failure due to acute coronary syndrome
B. Restrictive cardiomyopathy secondary to amyloidosis
C. Diastolic heart failure with preserved ejection fraction (HFpEF)
D. Systolic heart failure with reduced ejection fraction (HFrEF)
Explanation
Clinical Presentation Analysis
Key Diagnostic Features
Table
Feature
Finding
Significance
LVEF
52%
≥ 50% = Preserved EF
LV Wall Thickness
14 mm
Increased (normal < 11 mm); suggests LVH
LA Enlargement
Present
Chronic elevation of LV filling pressures
Mitral Inflow Pattern
E/A = 2.2 (E > A)
Restrictive/impaired relaxation pattern
E/e' Ratio
14
≥ 14 indicates elevated LV filling pressures
S3 Gallop
Absent
Argues against systolic HF
Lung Auscultation
Clear
No pulmonary edema clinically
Risk Factors
HTN, DM × 10 years
Classic for diastolic dysfunction
Diagnosis: HFpEF (Diastolic Heart Failure)
Key Point
This patient meets diagnostic criteria for heart failure with preserved ejection fraction (HFpEF), also called diastolic heart failure:
1.
Symptoms and signs of HF (dyspnea, fatigue, ankle edema, elevated JVP)
2.
LVEF ≥ 50% (preserved systolic function)
3.
Evidence of diastolic dysfunction:
Restrictive mitral inflow (E/A > 1 in restrictive pattern)
Elevated E/e' ratio (≥ 14 = elevated LV filling pressure)
LA enlargement (chronic pressure overload)
LVH (from chronic hypertension)
High-YieldNEET PG
HFpEF accounts for 40–50% of all HF cases, particularly in elderly women with hypertension and diabetes. The diagnosis requires both clinical HF symptoms AND evidence of diastolic dysfunction on echo.
Pathophysiology of HFpEF
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Clinical Pearl
In HFpEF, the problem is NOT weak contraction (systolic function is normal) but STIFF ventricles that don't relax well (diastolic dysfunction). This explains why inotropes and ACE-I have limited benefit.
Why Other Options Are Incorrect
Option 1: HFrEF
LVEF is 52% (≥ 50%), which is preserved, not reduced
HFrEF is defined as LVEF ≤ 40%; this patient's EF is normal
No S3 gallop (typical in HFrEF)
Trap: Some students confuse "heart failure" with "reduced EF" — HFpEF is equally common
