Does the development of a single classic heart failure (HF) symptom in a patient with diastolic dysfunction (DD) grade one automatically indicate heart failure (HF)?

No, Grade 1 Diastolic Dysfunction Does Not Automatically Become Heart Failure With a Single Symptom

The diagnosis of heart failure requires BOTH the presence of typical HF symptoms AND objective evidence of cardiac structural/functional abnormality causing those symptoms—not just the symptom alone. 1

Diagnostic Requirements for Heart Failure

The European Society of Cardiology clearly defines heart failure as a clinical syndrome characterized by typical symptoms (breathlessness, ankle swelling, fatigue) that may be accompanied by signs (elevated jugular venous pressure, pulmonary crackles, peripheral edema) caused by a structural and/or functional cardiac abnormality resulting in reduced cardiac output and/or elevated intracardiac pressures. 1

Demonstration of an underlying cardiac cause is central to the diagnosis of HF. 1 Simply having a symptom is insufficient—you must prove the symptom is caused by the cardiac abnormality.

Specific Criteria for Diastolic Heart Failure

For diastolic heart failure (HF with preserved ejection fraction), the diagnosis requires four conditions to be satisfied simultaneously: 2, 3

• Presence of signs or symptoms of heart failure 3
• Normal or mildly abnormal systolic LV function (LVEF >50% and LVEDVI <97 mL/m²) 3
• Evidence of diastolic LV dysfunction (invasively: LVEDP >16 mmHg or PCWP >12 mmHg; non-invasively: E/E' >15 or other supportive findings) 3
• Confirmation that the symptoms are caused by the diastolic dysfunction 1, 2

Why Grade 1 DD Plus One Symptom ≠ Automatic HF

Grade 1 diastolic dysfunction represents mild impairment and is extremely common in elderly individuals as part of normal aging. 2 Many patients with Grade 1 DD remain asymptomatic or have symptoms from other causes.

The critical distinction is that HF is not equivalent to cardiac dysfunction—these terms describe possible structural or functional reasons for HF, but HF itself is a clinical syndrome requiring both symptoms AND proof those symptoms arise from the cardiac abnormality. 1

There is a poor relation between measures of cardiac performance and symptoms. 1 Patients with very low ejection fraction may be asymptomatic, while patients with preserved LVEF may have severe disability from non-cardiac causes. 1

Common Pitfalls to Avoid

Do not diagnose HF based on a single symptom without excluding other causes. Dyspnea, fatigue, and edema can result from: 2

• Pulmonary disease (COPD, interstitial lung disease)
• Obesity and deconditioning
• Anemia
• Renal disease
• Venous insufficiency
• Medication side effects

Diastolic filling patterns can be altered by non-specific and transient changes in loading conditions, aging, heart rate changes, or mitral regurgitation—these do not automatically indicate symptomatic HF. 2

Diagnostic Approach for Grade 1 DD With Symptoms

When a patient with Grade 1 DD develops a potential HF symptom, you must: 2, 3

• Confirm the symptom is truly consistent with HF (not just isolated ankle swelling from venous disease or dyspnea from lung disease)
• Obtain objective evidence of elevated filling pressures causing the symptom (BNP/NT-proBNP elevation, echocardiographic evidence of increased filling pressures)
• Perform diastolic stress testing if Grade 1 DD at rest but symptoms with exertion (positive if average E/e' >14, peak TR velocity >2.8 m/sec, and septal e' <7 cm/sec during exercise) 2
• Exclude alternative explanations for the symptom

The most important intervention for Grade 1 diastolic dysfunction is aggressive blood pressure control, as hypertension is the primary modifiable risk factor for progression. 2, 4