Left Ventricular Hypertrophy is NOT a Criterion for HFrEF
The correct answer is (c) Left ventricular hypertrophy, as it is not a diagnostic criterion for heart failure with reduced ejection fraction.
Diagnostic Criteria for HFrEF
The diagnosis of HFrEF requires three essential components, and left ventricular hypertrophy is notably absent from these criteria:
Required Diagnostic Elements
1. Reduced Ejection Fraction (≤40%)
- The ACC/AHA guidelines define HFrEF as LVEF ≤40% 1
- This is the fundamental defining characteristic that distinguishes HFrEF from other heart failure phenotypes 1
- Measurement is typically obtained via echocardiography 2
2. Clinical Symptoms of Heart Failure
- Dyspnea, orthopnea, or exertional limitation are characteristic presenting symptoms 1, 2
- Physical examination findings may include bilateral edema, increased jugular venous pressure, or displaced apical beat 1
- These symptoms result from impairment of ventricular filling or ejection of blood 2
3. Elevated Natriuretic Peptides (BNP)
- BNP >35 pg/mL or NT-proBNP >125 pg/mL in the non-acute setting 1
- Higher thresholds apply in acute presentations: BNP >100 pg/mL or NT-proBNP >300 pg/mL 1
- Elevated natriuretic peptides have high negative predictive value (0.94-0.98) for ruling out heart failure 1
Why Left Ventricular Hypertrophy is NOT a Criterion
Left ventricular hypertrophy is a structural cardiac abnormality that:
- May be present in various cardiac conditions including hypertension and aortic stenosis 1
- Is more commonly associated with HFpEF (heart failure with preserved ejection fraction) rather than HFrEF 1
- Is not required for the diagnosis of HFrEF, which is primarily defined by reduced systolic function 1
Important distinction: While evidence of structural heart disease and increased filling pressures is required for diagnosing HFpEF (when LVEF ≥50%), this requirement does not apply to HFrEF 1. The presence of LVEF ≤40% itself provides sufficient evidence of cardiac dysfunction for HFrEF diagnosis 1.
Clinical Pitfall to Avoid
Do not confuse the diagnostic criteria for HFrEF with those for HFpEF. For HFpEF, objective evidence of cardiac structural alterations (which could include LV hypertrophy) is required in addition to preserved EF and elevated natriuretic peptides 1. However, for HFrEF, the reduced ejection fraction itself is the primary structural/functional abnormality needed for diagnosis 1.