Given a preserved left ventricular ejection fraction of 56% with mild concentric left ventricular hypertrophy and a small left ventricular cavity on echocardiogram, does the patient have heart failure?

Does She Have Heart Failure?

She may have heart failure with preserved ejection fraction (HFpEF), but the diagnosis cannot be confirmed based on the echocardiographic findings alone—you must establish the presence of typical heart failure symptoms and signs, and ideally measure natriuretic peptides (BNP >35 pg/mL or NT-proBNP >125 pg/mL) to complete the diagnostic criteria.

Diagnostic Framework for HFpEF

The 2016 ESC guidelines 1 establish that diagnosing HFpEF requires four mandatory conditions:

1. Symptoms typical of HF (breathlessness, ankle swelling, fatigue)
2. Signs typical of HF (elevated jugular venous pressure, pulmonary crackles, peripheral edema—though these may be absent in early stages)
3. Normal or only mildly reduced LVEF and non-dilated LV (your patient has EF 56% with small LV cavity—✓ satisfied)
4. Relevant structural heart disease AND/OR diastolic dysfunction (your patient has mild concentric LV hypertrophy—✓ satisfied)

What You're Missing

The echocardiogram shows structural abnormalities consistent with HFpEF (concentric LVH with preserved EF), but this alone is insufficient. According to the 2012 ESC guidelines 2, you need to document:

• Clinical symptoms and signs of heart failure (not provided in your question)
• Elevated natriuretic peptides (BNP ≥35 pg/mL or NT-proBNP ≥125 pg/mL) 1

Without symptoms/signs and biomarker elevation, this patient has asymptomatic structural heart disease—a precursor to heart failure but not yet clinical HF 1.

Additional Diagnostic Considerations

Echocardiographic Parameters to Assess

The 2016 ESC guidelines 1 and 2022 AHA/ACC guidelines 3 recommend evaluating:

• E/e' ratio: If ≥15, strongly suggests elevated filling pressures; if 9-14, intermediate probability 3
• Left atrial volume index (LAVI): Enlargement indicates chronically elevated filling pressures 1
• Tricuspid regurgitation velocity (TRV): Elevated values suggest pulmonary hypertension
• Tissue Doppler velocities (e'): Reduced values indicate diastolic dysfunction

The 2018 systematic review 4 found E/e' has only modest correlation with invasive filling pressures (r=0.56) in HFpEF, emphasizing that no single parameter reliably diagnoses HFpEF—you need an integrated assessment.

Clinical Context Matters

The 2023 ACC Expert Consensus 5 emphasizes excluding HFpEF mimics before confirming the diagnosis:

• Cardiac mimics: Infiltrative cardiomyopathy (amyloidosis), hypertrophic cardiomyopathy, pericardial disease, valvular disease
• Noncardiac mimics: Kidney disease, liver disease, chronic venous insufficiency, pulmonary disease

The H2FPEF score 3 can help estimate HFpEF probability using: obesity, atrial fibrillation, age >60 years, ≥2 antihypertensive medications, E/e' >9, and PA systolic pressure >35 mmHg. Scores ≥6 indicate high probability; <2 indicates low probability.

Practical Algorithm

Step 1: Document symptoms (dyspnea, fatigue, exercise intolerance) and signs (edema, elevated JVP, crackles)

Step 2: Measure natriuretic peptides

• If BNP <35 pg/mL or NT-proBNP <125 pg/mL → HF unlikely
• If elevated → proceed to Step 3

Step 3: Complete echocardiographic assessment

• Measure E/e', LAVI, e' velocity, TRV
• Assess for valvular disease, regional wall motion abnormalities

Step 4: If diagnosis remains uncertain with intermediate E/e' (9-14):

• Consider exercise stress echocardiography to assess diastolic parameters with provocation 3
• Consider invasive hemodynamics (right heart catheterization) to measure pulmonary capillary wedge pressure at rest or exercise 3

Step 5: Exclude mimics based on clinical presentation

• Screen for infiltrative disease if unexplained LVH, neuropathy, or age <60 with conduction disease 5
• Assess for hypertrophic cardiomyopathy if family history or LV outflow obstruction

Key Pitfalls

• Don't diagnose HFpEF based on echo alone: The structural findings (concentric LVH, preserved EF) are necessary but insufficient without clinical syndrome 1, 2
• Don't rely solely on E/e': It has limited diagnostic accuracy in isolation 4
• Don't miss treatable mimics: Cardiac amyloidosis, hypertrophic cardiomyopathy, and constrictive pericarditis require specific therapies 5
• Signs may be absent early: Especially in treated patients on diuretics 1, 2

Contemporary Perspective

The 2025 Canadian guidelines 6 now use the term "heart failure with nonreduced ejection fraction (HFnrEF)" for LVEF >40%, recognizing that patients across this spectrum respond similarly to key therapies (SGLT2 inhibitors, MRAs, ARNIs). However, diagnosis still requires the clinical syndrome, not just structural abnormalities.

The 2025 consensus statement 7 acknowledges LVEF has poor reproducibility and limited prognostic value above 45%, advocating for comprehensive assessment beyond a single LVEF measurement. This reinforces that your patient's EF of 56% with LVH represents a structural substrate, but clinical correlation determines whether heart failure is present.