A 58-year-old man with a 10-year history of hypertension presents with progressive dyspnea on exertion and orthopnea. Echocardiography shows reduced ejection fraction (35%) with concentric left ventricular hypertrophy. What is the most common cause of heart failure in this patient?

Question

Accepted Answer

A. Coronary artery disease. ## Most Common Cause of Heart Failure with Reduced Ejection Fraction (HFrEF)

**Key Point:** Coronary artery disease (CAD) is the most common cause of heart failure with **reduced ejection fraction (HFrEF)** globally, accounting for approximately 60–70% of HFrEF cases in developed nations (Harrison's Principles of Internal Medicine, 21e, Ch. 297).

### Why CAD, Not Hypertension, in This Context

While hypertension is the most common **risk factor** for heart failure overall, the distinction is critical:

- **Hypertension** predominantly causes **HFpEF** (preserved ejection fraction) via concentric LVH and diastolic dysfunction.
- **CAD / Ischemic cardiomyopathy** is the leading cause of **HFrEF** (reduced EF), as myocardial infarction and chronic ischemia lead to systolic dysfunction and ventricular remodeling.

This patient has an EF of **35%** — clearly HFrEF — making ischemic cardiomyopathy (CAD) the most likely underlying etiology.

### Pathophysiology of CAD-Induced HFrEF

1. **Myocardial ischemia / infarction** → Loss of contractile myocytes
2. **Ventricular remodeling** → Eccentric dilatation and systolic dysfunction
3. **Neurohormonal activation** (RAAS, SNS) → Further adverse remodeling
4. **Concentric LVH** can coexist due to long-standing hypertension as a comorbidity

### Epidemiology of HF Causes

| Cause | Predominant EF Pattern | Prevalence in HFrEF |
|-------|---|---|
| **Coronary artery disease** | **HFrEF** | **60–70%** |
| Hypertension | HFpEF (primarily) | ~10–15% of HFrEF |
| Valvular disease | Variable | 5–10% |
| Idiopathic cardiomyopathy | HFrEF | 5–10% |

**Clinical Pearl:** Concentric LVH in this patient reflects the hypertensive history, but the **reduced EF of 35%** is the key discriminator — it points to ischemic cardiomyopathy (CAD) as the primary driver of systolic dysfunction. Hypertension acts as a major risk factor and comorbidity, not the primary cause of HFrEF.

**High-Yield:** For NEET PG / INI-CET:
- Most common cause of **HF overall** → Hypertension (as a risk factor)
- Most common cause of **HFrEF specifically** → **Coronary artery disease**

[cite: Harrison 21e Ch. 297; Braunwald's Heart Disease, 12e]

Answer

B. Cardiomyopathy of unknown etiology

Answer

C. Valvular heart disease

Answer

D. Hypertension

A 58-year-old man with a 10-year history of hypertension presents with progressive dyspnea on exertion and orthopnea. Echocardiography shows reduced ejection fraction (35%) with concentric left ventricular hypertrophy. What is the most common cause of heart failure in this patient?

Explanation

Most Common Cause of Heart Failure with Reduced Ejection Fraction (HFrEF)

Why CAD, Not Hypertension, in This Context

Pathophysiology of CAD-Induced HFrEF

Epidemiology of HF Causes

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Cause	Predominant EF Pattern	Prevalence in HFrEF
Coronary artery disease	HFrEF	60–70%
Hypertension	HFpEF (primarily)	~10–15% of HFrEF
Valvular disease	Variable	5–10%
Idiopathic cardiomyopathy	HFrEF	5–10%