In a patient with grade II diastolic dysfunction on a two‑dimensional echocardiogram and a left ventricular ejection fraction of 72%, does this constitute heart failure with preserved ejection fraction?

Grade II Diastolic Dysfunction with LVEF 72%: Does This Constitute HFpEF?

Grade II diastolic dysfunction with an ejection fraction of 72% does NOT automatically constitute heart failure with preserved ejection fraction—the diagnosis requires the presence of typical heart failure symptoms (dyspnea, orthopnea, fatigue) or signs (pulmonary crackles, peripheral edema, elevated JVP) PLUS elevated natriuretic peptides or other objective evidence of elevated filling pressures. 1, 2

Core Diagnostic Requirements for HFpEF

The diagnosis of HFpEF demands three mandatory components that must all be present simultaneously:

• Clinical syndrome: Typical heart failure symptoms (exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea) and/or signs (pulmonary crackles, peripheral edema, elevated jugular venous pressure, S4 gallop) 1, 2

• Preserved systolic function: LVEF ≥ 50% on transthoracic echocardiography—your patient's LVEF of 72% clearly meets this threshold 1, 2

• Objective evidence of cardiac dysfunction: Either elevated natriuretic peptides (BNP >35 pg/mL or NT-proBNP >125 pg/mL in ambulatory setting) OR echocardiographic evidence of structural/functional abnormalities such as E/e' ratio >9–15, left atrial enlargement (LAVI), left ventricular hypertrophy (LVMI), or elevated pulmonary artery systolic pressure >35 mmHg 1, 2, 3

The Critical Distinction: Diastolic Dysfunction ≠ Heart Failure

Diastolic dysfunction and HFpEF are NOT identical entities—this is a common diagnostic pitfall. 4

• Grade II diastolic dysfunction represents an echocardiographic finding that indicates impaired left ventricular relaxation and elevated filling pressures 4, 3

• HFpEF is a clinical syndrome requiring symptoms/signs of heart failure in addition to the structural/functional abnormalities 1, 2, 5

• Many patients have diastolic dysfunction on echocardiography but remain asymptomatic and do not meet criteria for HFpEF 4, 6

Algorithmic Approach to This Patient

Step 1: Assess for Heart Failure Symptoms and Signs

If the patient is asymptomatic or has only non-specific symptoms:

• This represents diastolic dysfunction without heart failure 4, 6
• Aggressive management of underlying risk factors (hypertension, diabetes, obesity) is indicated to prevent progression 1, 3
• Serial monitoring with echocardiography and clinical assessment is warranted 2

If typical HF symptoms/signs are present, proceed to Step 2 1, 2

Step 2: Obtain Natriuretic Peptide Levels

• Measure BNP or NT-proBNP to confirm the diagnosis and exclude non-cardiac causes of dyspnea 1, 2
• Markedly elevated values provide diagnostic certainty for HFpEF 2
• Normal natriuretic peptides make HFpEF unlikely unless measured during diuretic therapy 1

Step 3: Integrate Echocardiographic Parameters

No single echocardiographic parameter is sufficient for diagnosis—an integrated assessment is required: 4, 3

• E/e' ratio: Values >15 indicate high filling pressures; values 9–15 are intermediate 1, 3
• Left atrial volume index (LAVI): Enlargement reflects chronic elevation of filling pressures 4, 1
• Left ventricular mass index (LVMI): Increased wall thickness from chronic hypertension 1
• Tricuspid regurgitation velocity (TRV): Elevated pulmonary artery pressure >35 mmHg 1

Step 4: Exclude HFpEF Mimics

Before confirming HFpEF, systematically rule out conditions requiring different treatment: 3

• Cardiac amyloidosis (especially in elderly patients)
• Hypertrophic cardiomyopathy
• Significant valvular disease (aortic stenosis, mitral regurgitation)
• Pericardial constriction
• High-output heart failure
• Infiltrative cardiomyopathies (sarcoidosis, hemochromatosis, Fabry disease) 1, 3

Management Implications

If HFpEF is confirmed (symptoms + elevated natriuretic peptides + structural abnormalities):

• Initiate SGLT2 inhibitor (empagliflozin 10 mg or dapagliflozin 10 mg daily) as first-line disease-modifying therapy—this reduces cardiovascular death and HF hospitalizations 2, 3

• Add mineralocorticoid receptor antagonist (spironolactone) to reduce morbidity and mortality 3

• Use loop diuretics judiciously for congestion management, not as disease-modifying therapy 3

• Aggressively manage comorbidities: target blood pressure <130/80 mmHg, optimize diabetes control, address obesity, manage atrial fibrillation if present 1, 3

If only diastolic dysfunction without HF symptoms:

• Focus on risk factor modification: aggressive blood pressure control, weight loss, diabetes management 1, 7
• Serial clinical and echocardiographic monitoring to detect progression 2
• Patient education about symptoms that should prompt re-evaluation 6

Common Pitfalls to Avoid

• Do not diagnose HFpEF based solely on echocardiographic diastolic dysfunction—clinical symptoms and elevated natriuretic peptides are mandatory 4, 1, 2

• Do not rely on E/e' ratio alone—it shows only modest correlation with invasive filling pressures in HFpEF populations and must be integrated with other parameters 4, 3

• Do not overlook HFpEF mimics—cardiac amyloidosis and hypertrophic cardiomyopathy require specific therapies and have different prognoses 3

• Do not assume all dyspnea in elderly patients with diastolic dysfunction is HFpEF—comorbidities (obesity, deconditioning, pulmonary disease, anemia) frequently contribute to symptoms and must be addressed 6, 7