Heart Failure with Preserved Ejection Fraction (HFpEF)
The most likely diagnosis is heart failure with preserved ejection fraction (HFpEF). This patient presents with the classic triad required for HFpEF diagnosis: typical heart failure symptoms (dyspnea, orthopnea, paroxysmal nocturnal dyspnea), preserved ejection fraction (55%), and structural cardiac abnormalities (left ventricular hypertrophy) in the setting of chronic hypertension. 1
Diagnostic Criteria Satisfied
This patient fulfills all mandatory criteria for HFpEF diagnosis as defined by current guidelines:
Clinical symptoms and signs of heart failure: The patient exhibits dyspnea, orthopnea, paroxysmal nocturnal dyspnea, pulmonary crackles, and an S4 gallop—all classic manifestations of heart failure. 1
Preserved ejection fraction: The echocardiogram demonstrates an LVEF of 55%, which exceeds the ≥50% threshold that defines preserved systolic function. 1
Structural cardiac abnormality: Left ventricular hypertrophy is present, which is the hallmark structural finding in HFpEF and reflects chronic pressure overload from hypertension. 1, 2
Hypertensive etiology: The blood pressure of 170/100 mmHg indicates uncontrolled hypertension, which is the predominant cause of HFpEF and occurs in the majority of cases worldwide. 1, 2, 3
Why Other Diagnoses Are Excluded
Heart failure with reduced ejection fraction (HFrEF) is definitively ruled out because the ejection fraction is 55%, well above the <40% threshold that defines HFrEF. 1
Ischemic cardiomyopathy is excluded by the echocardiographic findings showing no focal wall motion abnormalities, which would be expected if significant coronary artery disease were causing the heart failure. 1
Cor pulmonale with right ventricular failure is not supported by the clinical presentation. The patient has left-sided heart failure signs (pulmonary crackles, S4 gallop) without evidence of primary pulmonary disease or right ventricular dysfunction on echocardiography. 1
Pathophysiologic Basis
The S4 gallop is particularly telling in this case, as it reflects atrial contraction against a stiffened, hypertrophied left ventricle—a cardinal feature of diastolic dysfunction in HFpEF. 2
Age-related and hypertension-driven mechanisms explain this presentation:
Aging causes decreased elastic properties of the heart and great vessels, leading to increased systolic blood pressure and myocardial stiffness. 1, 2
Chronic hypertension produces concentric left ventricular hypertrophy, which is the structural hallmark of HFpEF. 2
The rate of ventricular filling decreases due to structural changes from fibrosis and decline in relaxation and compliance. 1, 2
Aging has a greater impact on ventricular filling characteristics than on ejection fraction, explaining why elderly patients develop HFpEF rather than HFrEF. 1, 2
Clinical Context
HFpEF is most prevalent among elderly patients (this patient is 68 years old) who present with typical heart failure symptoms including exertional dyspnea and orthopnea. 2
The absence of valvular abnormalities on echocardiography excludes important HFpEF mimics such as aortic stenosis or significant mitral regurgitation, which must be ruled out to confirm the diagnosis. 1, 2
Diagnostic Confirmation Steps
To complete the diagnostic workup, the following should be obtained:
Natriuretic peptides (BNP >35 pg/mL or NT-proBNP >125 pg/mL) to support the diagnosis and exclude alternative causes of dyspnea. 1, 2
Diastolic function parameters including E/e' ratio, left atrial volume index, and assessment for elevated filling pressures. 1, 4, 2
Exclusion of infiltrative cardiomyopathies (amyloidosis, sarcoidosis, hemochromatosis) and pericardial constriction through clinical assessment if clinical suspicion exists, though the presentation here is classic for hypertensive HFpEF. 1, 2