In a patient with pulmonary edema, dilated cardiac chambers, and preserved contractility, what is the appropriate diagnosis?

Heart Failure with Preserved Ejection Fraction (HFpEF)

The appropriate diagnosis is Heart Failure with Preserved Ejection Fraction (HFpEF), given the combination of pulmonary edema (cardiogenic congestion), dilated cardiac chambers (structural abnormality), and preserved contractility (normal ejection fraction ≥50%). 1

Diagnostic Framework

According to the 2023 ACC Expert Consensus, the Universal Definition of Heart Failure requires 1:

• Symptoms/signs of HF caused by structural/functional cardiac abnormality, PLUS
• At least one of the following:
  • Elevated natriuretic peptides (BNP >35 pg/mL ambulatory or >100 pg/mL hospitalized; NT-proBNP >125 pg/mL ambulatory or >300 pg/mL hospitalized)
  • Objective evidence of cardiogenic pulmonary or systemic congestion

Your patient meets these criteria through:

• Pulmonary edema = objective evidence of cardiogenic congestion
• Dilated cardiac chambers = structural cardiac abnormality
• Preserved contractility = EF ≥50%

Why HFpEF Specifically

The preserved contractility distinguishes this from HF with reduced ejection fraction (HFrEF). Dilated chambers with preserved contractility is a classic presentation of HFpEF, where diastolic dysfunction leads to elevated filling pressures despite maintained systolic function 1, 2.

The Framingham criteria support this diagnosis with major criteria present: acute pulmonary edema and cardiomegaly (dilated chambers) 1.

Critical Diagnostic Considerations

Important caveats to avoid misdiagnosis:

• Confirm the ejection fraction numerically - "contractility ok" should translate to EF ≥50% on echocardiography
• Measure natriuretic peptides if not already done - though pulmonary edema alone provides objective evidence of congestion, BNP/NT-proBNP helps confirm cardiac etiology 1
• Rule out HF mimics - particularly important in HFpEF where alternative diagnoses are common 1:
  • Pulmonary causes (pneumonia, COPD exacerbation)
  • Renal failure causing volume overload
  • Severe valvular disease (especially mitral regurgitation or stenosis)
  • Constrictive pericarditis
  • High-output states (thyroid disease, severe anemia)

Underlying Etiology Matters

While the diagnosis is HFpEF, you must identify the precipitating cause 3, 4:

• Uncontrolled hypertension - most common in acute presentations with pulmonary edema and preserved EF 3
• Atrial fibrillation with rapid ventricular response - loss of atrial kick worsens diastolic filling 4
• Acute coronary syndrome - can present as flash pulmonary edema even with preserved EF 5, 6
• Medication non-adherence or dietary indiscretion 4
• Arrhythmias (supraventricular tachycardia can cause flash pulmonary edema in HFpEF) 6
• Severe hypothyroidism - rare but reversible cause 7

Documentation Recommendation

Write the diagnosis as:

1. Primary diagnosis: "Heart Failure with Preserved Ejection Fraction (HFpEF)" or "Diastolic Heart Failure"
2. Secondary diagnosis: Specify the underlying etiology (e.g., "due to hypertensive emergency," "precipitated by atrial fibrillation with RVR")
3. Complications: "Acute cardiogenic pulmonary edema"

This approach captures both the syndrome (HFpEF) and guides treatment toward the precipitating factor, which is essential for preventing recurrence 3.