Is a patient with an ejection fraction (EF) of 60-65% and valve disease considered to have heart failure?

Heart Failure Diagnosis with EF 60-65% and Valve Disease

Yes, you can be diagnosed with heart failure even with an EF of 60-65% if you have valve disease, provided you meet the clinical criteria for heart failure—specifically, symptoms (dyspnea, fatigue, edema) plus either elevated natriuretic peptides or objective evidence of congestion. 1

Understanding the Diagnosis

Heart failure is fundamentally a clinical syndrome, not just an ejection fraction number. The diagnosis requires three components 1:

• Symptoms and/or signs: Dyspnea, fatigue, orthopnea, edema, rales, jugular venous distension, or third heart sound
• Structural/functional cardiac abnormality: This includes valve disease
• Either: Elevated natriuretic peptides (BNP >35 pg/mL ambulatory or >100 pg/mL hospitalized) OR objective evidence of cardiogenic congestion

Why EF Alone Doesn't Rule Out Heart Failure

Patients with preserved or even supranormal EF can have severe heart failure symptoms. 1 The correlation between EF and functional impairment is poor—patients with very low EF may be asymptomatic while those with preserved LVEF can be severely disabled. 1

With an EF of 60-65%, you would be classified as heart failure with preserved ejection fraction (HFpEF), defined as EF ≥50%. 1, 2

The Critical Role of Valve Disease

Valve disease is explicitly recognized as a structural cardiac abnormality that can cause heart failure, regardless of EF. 1 The comprehensive echocardiographic evaluation must address three fundamental questions 1:

1. Is the EF preserved or reduced?
2. Is the LV structure normal or abnormal?
3. Are there structural abnormalities such as valvular disease that could account for the clinical presentation?

Valvular heart disease can cause "secondary HFpEF"—where elevated filling pressures result from the valve pathology rather than primary diastolic dysfunction. 3 Early intervention for underlying valvular disease in this context generally improves symptoms and prolongs survival. 3

Important Diagnostic Considerations

When evaluating for HFpEF with valve disease, look for these specific echocardiographic findings 1, 4:

• E/E' ratio: Values >15 strongly suggest elevated filling pressures (though correlation is modest, with pooled r=0.56) 1, 4
• Left atrial enlargement: Indicates chronic pressure elevation 4
• Increased relative wall thickness: Suggests chronic pressure overload 4
• Short mitral deceleration time: Indicates elevated filling pressures 4

Common Pitfall to Avoid

Do not dismiss heart failure as a diagnosis simply because the EF is normal or supranormal on bedside echocardiogram. 5 This is a frequent error in emergency settings. Recent data shows that 21% of HFpEF patients have EF ≥60%, and these patients are characterized by more severe symptoms, hypertension, female sex, and valvular disease. 6

The Bottom Line

The presence of valve disease with an EF of 60-65% does NOT exclude heart failure—in fact, valve disease is a recognized structural cause of heart failure. 1, 3 The diagnosis hinges on whether you have clinical symptoms/signs of heart failure plus elevated natriuretic peptides or objective congestion, not on the EF value alone. 1