Does a 78‑year‑old man with normal left ventricular ejection fraction (57 %), mild left ventricular wall thickening, normal left ventricular wall motion, normal right ventricular systolic function (S′ ≈ 18 cm/s, TAPSE ≈ 2.0 cm), a calcified mitral annulus with mild mitral regurgitation, dilated aortic root (3.9 cm, indexed 1.7 cm/m²) and proximal ascending aorta (4.5 cm, indexed 1.9 cm/m²), normal inferior vena cava collapse (>50%) and no pericardial effusion meet criteria for heart failure?

Does This Patient Have Heart Failure?

No, this 78-year-old man does not meet diagnostic criteria for heart failure. Heart failure requires both characteristic symptoms (dyspnea, fatigue, reduced exercise tolerance) AND objective evidence of cardiac dysfunction—this patient has normal left ventricular systolic function (LVEF 57%), normal right ventricular function, and normal filling pressures (normal IVC collapse >50%), with no clinical symptoms described 1.

Core Diagnostic Requirements for Heart Failure

Heart failure is fundamentally a clinical syndrome, not merely an imaging diagnosis 1, 2. The diagnosis mandates three simultaneous elements:

• Symptoms: Dyspnea, fatigue, orthopnea, paroxysmal nocturnal dyspnea, or reduced exercise tolerance 1, 2
• Objective cardiac dysfunction: Structural or functional abnormality on imaging (reduced LVEF, diastolic dysfunction, valvular disease, or chamber enlargement) 1
• Elevated biomarkers OR congestion: Either elevated BNP/NT-proBNP OR objective signs of cardiogenic congestion (pulmonary edema, elevated filling pressures) 1, 2

This patient lacks the first requirement entirely—no symptoms are reported in the clinical presentation 2, 3.

Analysis of This Patient's Echocardiographic Findings

Normal Systolic Function

• LVEF 57% is definitively normal (≥50% defines preserved ejection fraction) 1
• Normal biventricular systolic function with TAPSE 2.0 cm (normal ≥1.7 cm) and RV S' 18.4 cm/s (normal >9.5 cm/s) 1
• Normal segmental wall motion excludes regional ischemic dysfunction 1

Mild Structural Abnormalities Present

• Mild LV wall thickening: Common in elderly hypertensive patients; does not constitute heart failure without symptoms and elevated filling pressures 1
• Calcified mitral annulus with mild mitral regurgitation: Age-related degenerative finding that increases cardiovascular risk but does not define heart failure 4, 5. Mild functional mitral regurgitation in the absence of symptoms or elevated filling pressures is insufficient for diagnosis 6, 7
• Dilated aortic root (3.9 cm, indexed 1.7 cm/m²) and ascending aorta (4.5 cm, indexed 1.9 cm/m²): Mild aortic dilatation that requires surveillance but does not cause heart failure 8

Critical Evidence Against Heart Failure

• Normal IVC collapse >50%: Indicates normal right atrial pressure (~3 mmHg), definitively excluding elevated filling pressures and volume overload 1
• No pericardial effusion: Rules out pericardial constriction or tamponade 1

Why Preserved LVEF Does Not Equal "No Heart Failure"—But This Patient Still Doesn't Have It

Heart failure with preserved ejection fraction (HFpEF) accounts for 40-50% of all heart failure cases 1, 9. However, HFpEF diagnosis requires:

1. Symptoms of heart failure (dyspnea, fatigue, exercise intolerance) 1
2. LVEF ≥50% (met in this patient) 1
3. Evidence of diastolic dysfunction: Elevated filling pressures demonstrated by E/e' ratio >14 (average) or >15 (septal), elevated BNP/NT-proBNP, left atrial enlargement, or LV hypertrophy 1

This patient has no symptoms and normal filling pressures (normal IVC collapse), which excludes HFpEF despite mild LV wall thickening 1, 2.

ACC/AHA Staging: Where Does This Patient Fit?

The ACC/AHA staging system classifies patients based on structural disease and symptom history 1, 3:

• Stage A: At risk (hypertension, diabetes, CAD) but no structural disease or symptoms
• Stage B: Structural heart disease (LV hypertrophy, prior MI, valvular disease) but never had symptoms
• Stage C: Structural disease with current or prior symptoms of heart failure
• Stage D: Refractory heart failure requiring advanced therapies

This patient is Stage B at most—he has mild structural abnormalities (LV wall thickening, mitral annular calcification, mild MR, aortic dilatation) but no documented symptoms 1, 3. Stage B patients have increased cardiovascular risk and warrant preventive therapies (ACE inhibitors, beta-blockers if post-MI or reduced LVEF) but do not have heart failure 1.

Critical caveat: If this patient has undocumented symptoms (dyspnea, fatigue, exercise intolerance), he would be Stage C, and the diagnosis changes entirely 3. Direct questioning about exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and exercise tolerance is mandatory 1, 2.

Common Diagnostic Pitfalls to Avoid

Pitfall 1: Equating Structural Abnormalities with Heart Failure

• Mild LV hypertrophy, mitral annular calcification, and mild mitral regurgitation are common age-related findings in elderly patients 1, 4, 5
• Heart failure is not equivalent to cardiomyopathy or LV dysfunction—it is a clinical syndrome requiring symptoms 1, 2

Pitfall 2: Assuming Absence of Edema Rules Out Heart Failure

• Many heart failure patients, especially early or well-treated cases, have no peripheral edema 1, 2
• Conversely, edema alone (without dyspnea, elevated filling pressures, or cardiac dysfunction) does not confirm heart failure 2

Pitfall 3: Ignoring the Importance of Symptoms

• A completely normal exercise test in an untreated patient excludes heart failure 1
• Asymptomatic patients with structural abnormalities have asymptomatic LV dysfunction (Stage B), not heart failure 1, 3

Pitfall 4: Overlooking Normal Filling Pressures

• Normal IVC collapse >50% indicates right atrial pressure ~3 mmHg, excluding volume overload and elevated filling pressures 1
• This single finding strongly argues against heart failure in the absence of symptoms 1

What This Patient Needs

1. Symptom assessment: Direct questioning about dyspnea (exertional, at rest, orthopnea, PND), fatigue, and exercise tolerance 1, 2
2. Risk factor management: Control hypertension (likely given LV wall thickening), treat dyslipidemia, manage diabetes if present 1
3. Surveillance of structural abnormalities: Monitor aortic dilatation (repeat imaging if ascending aorta approaches 5.0 cm), assess progression of mitral regurgitation 5, 8
4. Consider BNP/NT-proBNP if symptoms emerge: Elevated natriuretic peptides would support heart failure diagnosis; normal levels (BNP <35 pg/mL, NT-proBNP <125 pg/mL) effectively rule it out 1, 2

Bottom line: This patient has mild age-related structural cardiac abnormalities (Stage B) but does not have heart failure in the absence of symptoms and with normal filling pressures. The diagnosis hinges entirely on whether symptoms exist—if dyspnea, fatigue, or exercise intolerance are present, reassess with natriuretic peptides and diastolic function parameters 1, 2, 3.