Can I have heart failure (HF) with an ejection fraction (EF) of 55-60%, normal electrocardiogram (ECG), brain natriuretic peptide (BNP) level less than 10, and diastolic dysfunction grade 1?

Can You Have Heart Failure with These Parameters?

You are extremely unlikely to have clinically significant heart failure given your combination of normal ECG, BNP <10 pg/mL, and preserved ejection fraction of 55-60%, despite having grade 1 diastolic dysfunction. 1

Why Heart Failure Is Unlikely

BNP Level Rules Out Active Heart Failure

• Your BNP of <10 pg/mL falls well below the diagnostic threshold for heart failure, which requires BNP >100 pg/mL to suggest chronic HF is likely 1
• The European Society of Cardiology guidelines explicitly state that BNP <100 pg/mL makes chronic heart failure "unlikely" 1
• For acute presentations, even the lower exclusion threshold is 100 pg/mL for BNP, and your level is one-tenth of this 1
• A normal BNP level combined with a completely normal ECG makes heart failure, especially with systolic dysfunction, unlikely (<10% probability) 1

Normal ECG Is Highly Reassuring

• The ESC guidelines emphasize that if the ECG is completely normal, heart failure—particularly with systolic dysfunction—is unlikely (<10% probability) 1
• Your normal ECG combined with preserved EF essentially excludes reduced ejection fraction heart failure 1

Grade 1 Diastolic Dysfunction Context

• Grade 1 diastolic dysfunction (impaired relaxation) is the mildest form and is extremely common in people over 60 years old, often representing normal aging rather than disease 2
• In hypertensive patients with grade 1 diastolic dysfunction and normal EF, 79% have BNP levels within the normal range, and these patients typically do not have clinically significant heart failure 3
• BNP levels in patients with mild diastolic dysfunction average around 35-46 pg/mL, but yours is even lower at <10 pg/mL 3

Do You Have a Weak or Strong Heart?

Your heart is functionally strong, not weak. 1

Evidence of Strong Heart Function

• Your ejection fraction of 55-60% is normal and indicates preserved systolic function—this means your heart squeezes effectively 1
• Heart failure with reduced ejection fraction (HFrEF) is defined as EF ≤40%, and you are well above this threshold 1, 4
• Your EF places you in the normal range (≥50% defines HF with preserved EF if HF were present, but you don't meet criteria for HF) 1

What Grade 1 Diastolic Dysfunction Means

• Grade 1 diastolic dysfunction indicates your heart muscle is slightly stiffer than ideal during the filling phase, but this is not the same as having a weak heart 2
• This represents impaired relaxation, which is the earliest and mildest form of diastolic abnormality 5
• At age 70, mild diastolic changes are common and do not necessarily indicate heart disease requiring treatment 2, 3

Important Clinical Caveats

When to Reconsider the Diagnosis

• If you develop new symptoms such as progressive shortness of breath, leg swelling, orthopnea (difficulty breathing when lying flat), or paroxysmal nocturnal dyspnea, reassessment would be warranted 1
• If you have unexplained exertional dyspnea despite these normal tests, exercise testing or stress echocardiography might reveal elevated filling pressures with exertion that aren't apparent at rest 1
• The 2022 ACC/AHA guidelines note that HF with preserved EF can be challenging to diagnose and may require evidence of elevated filling pressures during provocation (exercise, fluid challenge) 1

Conditions That Could Explain Your Findings

• You may be in Stage B heart failure (pre-heart failure)—meaning you have structural changes (grade 1 diastolic dysfunction) but no symptoms or clinical HF 1
• Stage B patients have risk factors and structural abnormalities but do not have active heart failure and do not require HF-specific medications 1
• Focus should be on managing cardiovascular risk factors (hypertension, diabetes, cholesterol) to prevent progression 1

Why Some Patients with HFpEF Have Normal BNP

• While 29% of patients with confirmed HF with preserved EF can have normal BNP levels (≤100 pg/mL), these patients typically still have BNP levels higher than yours, and they have confirmed symptoms and elevated filling pressures on invasive testing 6
• Your BNP of <10 pg/mL is exceptionally low and strongly argues against any significant cardiac dysfunction 6