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Heart failure with preserved EF — ABIM Board MCQ

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HardCardiovascularHeart failure with preserved EFABIM Board

A 72-year-old woman with a BMI of 36 kg/m² and hypertension treated with 3 medications has progressive exertional dyspnea. She is euvolemic at rest. Hemoglobin concentration, thyroid function, spirometry, and resting oxygen saturation are normal. Echocardiography shows an LVEF of 62%, mild left atrial enlargement, an average E/e′ ratio of 11, estimated pulmonary artery systolic pressure of 32 mm Hg, and no significant valvular or pericardial disease. BNP is 68 pg/mL. Diastolic stress echocardiography is technically nondiagnostic. Which of the following is the most appropriate diagnostic study to determine whether her symptoms are due to occult heart failure with preserved ejection fraction?

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Correct answer: A — Right heart catheterization with exercise hemodynamics

Right heart catheterization with exercise hemodynamics is the definitive study when HFpEF remains suspected but resting and noninvasive findings are indeterminate. Obesity, older age, resistant hypertension, mild left atrial enlargement, and an E/e′ ratio above 9 raise the pretest probability; however, the patient is euvolemic, BNP is not clearly elevated, and stress echocardiography was nondiagnostic. Exercise catheterization can demonstrate an abnormal rise in pulmonary artery wedge pressure, confirming occult HFpEF and distinguishing it from pulmonary vascular disease or noncardiac dyspnea. Coronary calcium scoring estimates atherosclerotic burden but does not establish the cause of dyspnea. Ventilation-perfusion scanning is primarily used for suspected chronic thromboembolic disease. Endomyocardial biopsy requires suspicion for a specific infiltrative or inflammatory disorder. Tilt-table testing evaluates orthostatic syncope or intolerance, neither of which is present.

Reference: American Heart Association. Standardization of Baseline and Provocative Invasive Hemodynamic Protocols for the Evaluation of Heart Failure and Pulmonary Hypertension: Top Things to Know. 2026. https://professional.heart.org/en/science-news/standardization-of-baseline-and-provocative-invasive-hemodynamic-protocols-for-the-evaluation/top-things-to-know