Does a normal ejection fraction of 60–65% with indeterminate diastolic function on echocardiogram indicate heart failure?

Does This Echocardiogram Indicate Heart Failure?

No, an ejection fraction of 60-65% with indeterminate diastolic function does NOT automatically mean heart failure—the diagnosis of heart failure is fundamentally a clinical diagnosis that requires symptoms and signs of heart failure, not just echocardiographic findings alone. 1, 2

Understanding the Clinical Context

The diagnosis of heart failure with preserved ejection fraction (HFpEF) requires three mandatory components to be satisfied simultaneously 1:

• Clinical symptoms and signs of heart failure (dyspnea, edema, elevated jugular venous pressure, pulmonary congestion)
• Preserved left ventricular systolic function (LVEF ≥45-50%)—which this patient has
• Evidence of diastolic dysfunction AND/OR structural cardiac abnormalities—which is indeterminate in this case

Your patient meets only one of these three criteria. Without clinical evidence of heart failure, this echocardiogram alone cannot establish the diagnosis. 1, 2

What "Indeterminate Diastolic Function" Means

The term "indeterminate" indicates that the echocardiographic parameters fall into a gray zone where diastolic function cannot be confidently classified as normal or abnormal 3. This occurs in approximately 10-11% of cases when applying current diagnostic algorithms. 3

Key point: Indeterminate diastolic function is NOT the same as proven diastolic dysfunction. The ACC/AHA guidelines explicitly recognize that heart failure with normal systolic function requires demonstrable evidence of diastolic dysfunction, not just uncertainty about it. 3

What Additional Information You Need

To determine if this patient has HFpEF, you must assess 1, 2:

Clinical Assessment

• Symptoms: Dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, exercise intolerance 3
• Signs: Elevated jugular venous pressure, peripheral edema, pulmonary rales, S3 gallop 3
• Natriuretic peptides: BNP or NT-proBNP levels to support or refute the diagnosis 1, 2

Additional Echocardiographic Parameters

The echocardiogram should have documented 1:

• E/e' ratio: >15 indicates high filling pressures, <8 suggests normal pressures 1
• Septal e' velocity: <7 cm/sec indicates impaired relaxation 1
• Lateral e' velocity: <10 cm/sec indicates impaired relaxation 1
• Left atrial volume index (LAVI): >34 mL/m² reflects chronic elevated filling pressures 1
• Left ventricular mass index (LVMI): >115 g/m² (men) or >95 g/m² (women) indicates LV hypertrophy 1
• Tricuspid regurgitation velocity (TRV) and estimated pulmonary artery pressures 1

No single echocardiographic parameter can reliably diagnose HFpEF; an integrated assessment of multiple markers is mandatory. 1

Critical Diagnostic Pitfall

Even if you establish that the patient has symptoms AND diastolic dysfunction, you must systematically exclude HFpEF mimics that require entirely different treatment approaches 2:

• Cardiac amyloidosis: Look for increased wall thickness with "sparkling" appearance, low voltage on ECG 3
• Hypertrophic cardiomyopathy: Asymmetric septal hypertrophy (septal/posterior wall ratio >1.3), systolic anterior motion of mitral valve 1
• Constrictive pericarditis: Pericardial thickening >3-4 mm, respiratory variation in mitral inflow >25%, septal bounce 1
• Restrictive cardiomyopathy: Normal ventricular size with atrial enlargement, characteristic Doppler inflow patterns 3

The Bottom Line

This echocardiogram shows normal systolic function with uncertain diastolic assessment—it neither confirms nor excludes heart failure. 3, 1 The patient needs:

1. Clinical correlation: Are there symptoms/signs of heart failure? 3, 2
2. Natriuretic peptide testing: To support or refute the diagnosis 2
3. Complete diastolic function assessment: Request specific measurement of E/e', e' velocities, LAVI, and LVMI 1
4. Consider stress echocardiography: If symptoms occur only with exertion, as exercise echo has higher sensitivity for detecting elevated filling pressures 3

Remember that ejection fraction is a load-dependent parameter and does not directly measure intrinsic contractility—patients can have preserved EF yet still have impaired myocardial function detectable by other methods like global longitudinal strain. 4, 5 However, the presence of abnormal myocardial function alone, without clinical heart failure syndrome, does not constitute a diagnosis of heart failure. 3, 1, 2