Can a patient have heart failure with a preserved ejection fraction of 83% despite a hyperdynamic left ventricular function and concentric left ventricular hypertrophy?

Yes, Heart Failure Can Occur with an EF of 83% and Hyperdynamic LV Function with Concentric LVH

A patient with an ejection fraction of 83%, hyperdynamic left ventricular function, and concentric left ventricular hypertrophy can absolutely have heart failure—specifically, heart failure with preserved ejection fraction (HFpEF). This presentation is entirely consistent with established diagnostic criteria and represents a well-recognized pathophysiologic phenotype 1.

Diagnostic Framework

According to the 2016 ESC Guidelines, HFpEF is defined by:

• Clinical symptoms and signs of heart failure (breathlessness, fatigue, ankle swelling, elevated jugular venous pressure, pulmonary crackles, peripheral edema)
• LVEF ≥50% (your patient at 83% clearly meets this)
• Evidence of structural and/or functional cardiac abnormality causing reduced cardiac output and/or elevated intracardiac pressures 1

Your patient's concentric LVH fulfills the structural abnormality requirement. The hyperdynamic function (EF 83%) does not exclude HFpEF—in fact, it may indicate a specific pathophysiologic subtype.

The Hyperdynamic Phenotype in HFpEF

Recent invasive hemodynamic studies demonstrate that patients with HFpEF and LVEF >60% represent a distinct subphenotype characterized by:

• Hypercontractile state with elevated end-systolic elastance
• Excessive passive diastolic stiffness (higher β constant)
• Impaired preload reserve with exaggerated increases in LV filling pressures during exercise
• Paradoxical decrease in stroke volume under exertion despite the high resting EF 2

This means your patient's hyperdynamic function at rest may actually worsen their hemodynamics during activity—the LV becomes so stiff that it cannot adequately fill, leading to reduced stroke volume when it matters most.

Role of Concentric LVH

Concentric LVH is a cardinal feature of HFpEF and serves multiple pathophysiologic roles:

• It is the most common structural abnormality in HFpEF 3
• Causes of diastolic heart failure explicitly include myocardial hypertrophy 4
• The combination of LV mass index and maximal left atrial volume best identifies HFpEF patients (84% sensitivity, 82% specificity) 5
• Concentric remodeling leads to diastolic dysfunction through extracellular matrix changes, vascular dysfunction, and altered cardiomyocyte mechano-elastic properties 3, 6

Critical Diagnostic Requirements

To confirm HFpEF in your patient, you must document:

1. Symptoms/signs of heart failure (not just structural abnormalities)
2. Elevated natriuretic peptides (BNP >35 pg/mL or NT-proBNP >125 pg/mL) 1
3. Evidence of diastolic dysfunction via:
   • Echocardiographic parameters (E/e' ratio, left atrial enlargement)
   • Invasive hemodynamics showing elevated filling pressures
   • Clinical evidence of congestion 4

Important Caveats

You must exclude HFpEF mimics before making this diagnosis:

• Hypertrophic cardiomyopathy (though concentric LVH is present, look for asymmetric septal hypertrophy, systolic anterior motion, genetic markers) 7
• Infiltrative cardiomyopathies (amyloidosis, sarcoidosis)
• Valvular disease (especially aortic stenosis)
• Pericardial disease
• High-output states 1, 7

The diagnosis of HFpEF is more challenging than HFrEF and requires careful exclusion of non-cardiac causes of dyspnea 1.

Management Implications

Treatment differs fundamentally from HFrEF:

• Beta-blockers to lower heart rate and increase diastolic filling period 4
• Diuretics cautiously for congestion—but avoid excessive preload reduction which can worsen stroke volume in this hyperdynamic, stiff ventricle 4
• ACE inhibitors may improve relaxation and promote regression of hypertrophy 4
• Treat underlying hypertension aggressively as this drives the concentric remodeling 4
• Consider SGLT2 inhibitors based on emerging evidence in HFpEF 8

Common pitfall: Assuming normal or high EF means the patient cannot have heart failure. The ESC guidelines explicitly state that "heart failure with preserved left ventricular systolic function and that due to diastolic dysfunction are not synonymous" but overlap significantly 4. Your patient's hyperdynamic function may mask underlying diastolic pathology that becomes clinically apparent during stress.

Bottom line: An EF of 83% with hyperdynamic function and concentric LVH is entirely compatible with—and may even be characteristic of—a specific HFpEF phenotype. The key is documenting symptoms, elevated filling pressures, and excluding alternative diagnoses.