Do symptoms and evidence of structural heart damage, such as left ventricular ejection fraction (LVEF) abnormality, both need to be present for a diagnosis of heart failure in a patient with a history of hypertension, diabetes, and coronary artery disease?

Diagnosis of Heart Failure: Symptoms AND Structural Damage Required

Yes, both symptoms (or signs) AND evidence of structural or functional cardiac abnormality are required for a diagnosis of heart failure, regardless of ejection fraction. Heart failure is fundamentally a clinical syndrome, not simply an imaging finding or laboratory value 1, 2.

The Three Essential Diagnostic Components

The ACC/AHA explicitly defines heart failure as requiring all three elements 2:

• Symptoms and/or signs: dyspnea, fatigue, orthopnea, edema, rales, jugular venous distension, or third heart sound
• Structural or functional cardiac abnormality: reduced LVEF, left ventricular hypertrophy (LVH), left atrial enlargement, valvular disease, wall motion abnormalities, or diastolic dysfunction
• Objective evidence: either elevated natriuretic peptides (BNP >35 pg/mL ambulatory or >100 pg/mL hospitalized) OR objective evidence of pulmonary/systemic congestion 2

Why Both Are Necessary

Heart failure is not equivalent to cardiomyopathy or left ventricular dysfunction alone—these describe structural reasons for developing heart failure, but the diagnosis itself requires the clinical syndrome 1. A patient with reduced LVEF who is completely asymptomatic does not have heart failure; they have Stage B disease (structural heart disease without symptoms) 1.

Conversely, symptoms alone without structural abnormality do not constitute heart failure. The ACC/AHA staging system explicitly distinguishes 1:

• Stage A: Risk factors (hypertension, diabetes, CAD) without structural disease or symptoms
• Stage B: Structural heart disease (LV remodeling, reduced LVEF, LVH, valvular disease) WITHOUT symptoms
• Stage C: Structural heart disease WITH current or prior symptoms—this is when heart failure diagnosis is made
• Stage D: Refractory heart failure requiring advanced interventions

Special Considerations for HFpEF

For heart failure with preserved ejection fraction (LVEF ≥50%), the diagnostic challenge is greater because LVEF is normal 1, 2. The ESC guidelines require 1:

• Clinical symptoms/signs consistent with heart failure
• Elevated natriuretic peptides (BNP ≥35 pg/mL or NT-proBNP ≥125 pg/mL)
• Objective evidence of structural/functional abnormality: left atrial volume index >34 mL/m², LVMI ≥115 g/m² (males) or ≥95 g/m² (females), E/e' ≥13, or mean e' <9 cm/s 1

Most patients with HFpEF will have detectable structural abnormalities including LVH, atrial dilation, mitral annular calcification, aortic sclerosis, or myocardial scar, even when LVEF is preserved 1. In your patient with hypertension, diabetes, and CAD, these structural changes are highly likely present 1.

Clinical Pitfalls to Avoid

A normal ECG and BNP <35 pg/mL or NT-proBNP <125 pg/mL make heart failure unlikely, regardless of structural findings 1. This is a critical screening tool.

Do not diagnose heart failure based on imaging alone. Asymptomatic LV dysfunction, LVH, or diastolic abnormalities represent Stage B disease requiring preventive therapy (ACE inhibitors, beta-blockers) but not a heart failure diagnosis 1.

Symptoms must be cardiac in origin. Many noncardiac factors contribute to dyspnea and exercise intolerance in patients with risk factors—pulmonary disease, deconditioning, obesity, anemia 1. The structural abnormality must plausibly explain the symptoms.

Diagnostic Algorithm for Your Patient

In a patient with hypertension, diabetes, and CAD presenting with potential heart failure symptoms 1:

1. Confirm symptoms/signs: dyspnea, orthopnea, edema, rales, elevated JVP, S3 gallop
2. Measure natriuretic peptides: BNP or NT-proBNP as initial screening 1, 2
3. Obtain echocardiography to assess LVEF and identify structural abnormalities: LVH, chamber dilation, wall motion abnormalities, valvular disease, diastolic dysfunction parameters (E/e', left atrial size) 1
4. Integrate findings: Heart failure diagnosis requires symptoms PLUS structural/functional abnormality PLUS elevated natriuretic peptides or objective congestion 2

The diagnosis cannot be made with structural abnormality alone, nor with symptoms alone—both must coexist to establish the clinical syndrome of heart failure 1, 2.