Heart Failure with Reduced Ejection Fraction (HFrEF)
This patient has HFrEF (Heart Failure with Reduced Ejection Fraction), which is Answer A. The ejection fraction of 32% definitively places this patient in the HFrEF category, as this is well below the 40% threshold that distinguishes HFrEF from other heart failure phenotypes 1.
Classification Based on Ejection Fraction
The European Society of Cardiology and American College of Cardiology define heart failure phenotypes strictly by left ventricular ejection fraction (LVEF) 1, 2:
- HFrEF: LVEF <40% - This patient's EF of 32% falls clearly into this category 1, 2
- HFmrEF (Heart Failure with Mid-Range EF): LVEF 40-49% - This represents a "grey area" between HFrEF and HFpEF 1
- HFpEF (Heart Failure with Preserved EF): LVEF ≥50% - Characterized by preserved systolic function with diastolic dysfunction 1, 3
Why This is NOT Mixed Systolic and Diastolic Failure
The term "mixed systolic and diastolic failure" (Answer D) is not a recognized classification in current guidelines 1. This terminology is outdated because:
- Most patients with HFrEF (systolic dysfunction) also have diastolic dysfunction present 1
- Conversely, patients with HFpEF (diastolic dysfunction) often have subtle systolic abnormalities 1
- Current classification is based solely on LVEF measurement, not on the mechanistic distinction between systolic vs diastolic dysfunction 1
Clinical Presentation Confirms HFrEF
This patient's presentation is classic for HFrEF 2:
- Progressive dyspnea - indicating worsening cardiac output 1
- Orthopnea requiring 3 pillows - a sign of elevated left ventricular filling pressures and pulmonary congestion 4
- Reduced ejection fraction (32%) - demonstrating impaired systolic contractility 1, 2
The mild tricuspid regurgitation is a common finding in HFrEF and does not change the primary classification 5. Moderate/severe TR occurs in approximately 10% of HFrEF patients and is associated with worse outcomes, but mild TR is even more prevalent and does not alter the fundamental diagnosis 5.
Important Clinical Caveat
While the ejection fraction clearly defines this as HFrEF, the presence of orthopnea (sleeping with 3 pillows) is prognostically significant 4. In patients with heart failure, orthopnea is one of the most predictive individual symptoms for adverse cardiovascular events and should prompt aggressive guideline-directed medical therapy 4.