Diagnosis: Heart Failure with Preserved Ejection Fraction (HFpEF)
The diagnosis is C: Heart Failure with Preserved Ejection Fraction (HFpEF). This older patient presents with classic HFpEF: exertional dyspnea and heart failure symptoms, normal ejection fraction (60%), and concentric left ventricular hypertrophy on echocardiography 1.
Diagnostic Reasoning
Why HFpEF is the Correct Diagnosis
The patient meets the core diagnostic criteria for HFpEF:
- EF ≥50% (this patient has 60%, which is normal) 1
- Symptoms and signs of heart failure (exertional dyspnea and other HF symptoms) 1, 2
- Structural cardiac abnormality (concentric LVH is a key structural alteration supporting HFpEF diagnosis) 1, 2
The 2022 ACC/AHA guidelines explicitly state that HFpEF diagnosis requires evidence of structural heart disease, with increased LV mass (concentric LVH) being a key structural alteration 1. This patient has exactly this finding.
Why NOT Restrictive Cardiomyopathy (Option A)
Restrictive cardiomyopathy is a specific infiltrative disease (amyloidosis, sarcoidosis, hemochromatosis) that presents differently 1:
- Restrictive cardiomyopathy typically shows biatrial enlargement, restrictive filling patterns, and often reduced longitudinal strain despite preserved EF 1
- The question describes concentric LVH, which is the classic pattern of hypertensive heart disease leading to HFpEF, not the infiltrative pattern of restrictive disease 1, 2
- Restrictive cardiomyopathy is a HFpEF mimic that should be excluded, not the primary diagnosis in an older patient with typical risk factors 2
Why NOT Constrictive Pericarditis (Option B)
Constrictive pericarditis has distinct features absent in this case 1:
- Requires pericardial thickening on imaging
- Shows ventricular interdependence and respiratory variation in filling patterns
- Does not typically present with concentric LVH
- The echocardiographic finding of concentric LVH points to myocardial disease, not pericardial disease 1
Clinical Context and Diagnostic Approach
Supporting the HFpEF Diagnosis
The 2022 ACC/AHA guidelines provide a diagnostic algorithm 1:
- Confirm HF symptoms (✓ exertional dyspnea present)
- Measure natriuretic peptides (BNP >35 pg/mL or NT-proBNP >125 pg/mL supports diagnosis) 1, 2
- Confirm LVEF ≥50% (✓ EF is 60%)
- Document structural/functional cardiac abnormality (✓ concentric LVH present) 1
Concentric LVH is specifically mentioned as evidence supporting HFpEF because it indicates chronic pressure overload (typically from hypertension) causing diastolic dysfunction 1.
Additional Diagnostic Considerations
If the diagnosis remains uncertain after initial assessment 1, 2:
- Check E/e' ratio on echocardiography (E/e' ≥15 indicates elevated filling pressures at rest; E/e' >9 supports HFpEF) 1, 3
- Measure left atrial volume index (enlargement supports chronic elevated filling pressures) 1, 2
- Consider H2FPEF score (incorporates age >60, hypertension requiring ≥2 medications, obesity, atrial fibrillation, E/e' >9, PA systolic pressure >35 mmHg; score ≥6 indicates high probability of HFpEF) 1, 3, 4
- If still uncertain, perform exercise stress echocardiography to assess for elevated filling pressures with exertion (exercise E/e' >14 or exercise PCWP ≥25 mmHg confirms HFpEF) 1, 5
Common Pitfalls to Avoid
Do not confuse HFpEF with its mimics 2:
- Always exclude valvular disease (especially aortic stenosis and mitral regurgitation) 1, 2
- Rule out infiltrative diseases if clinical features suggest them (but concentric LVH from hypertension is far more common than infiltrative disease in older patients) 2
- Remember that HFpEF is a clinical diagnosis requiring integration of symptoms, structural findings, and evidence of elevated filling pressures 1
The presence of concentric LVH with normal EF in an older patient with exertional dyspnea is the classic presentation of HFpEF, not restrictive cardiomyopathy 1, 6. Restrictive cardiomyopathy would require specific evidence of infiltrative disease and typically shows different echocardiographic patterns 1, 2.