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Heart failure with preserved EF — ABIM Board MCQ

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ModerateCardiovascularHeart failure with preserved EFABIM Board

A 76-year-old woman has progressive exertional dyspnea, orthopnea, and bilateral lower-extremity edema. She has hypertension, obesity, and atrial fibrillation. Echocardiography shows an LVEF of 64%, increased left ventricular wall thickness with a normal-sized ventricular cavity, left atrial enlargement, impaired relaxation, and an average E/e′ ratio of 16. There is no significant valvular disease. Coronary angiography shows no obstructive coronary disease. Which of the following abnormalities most directly accounts for her elevated cardiac filling pressures and congestion?

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Correct answer: B — Reduced ventricular compliance from concentric remodeling

This patient has heart failure with preserved ejection fraction (HFpEF): clinical congestion, LVEF greater than 50%, and evidence of elevated left ventricular filling pressure, including left atrial enlargement and an E/e′ ratio of 16. Long-standing hypertension promotes concentric remodeling and myocardial stiffening. The resulting reduction in ventricular compliance causes a large rise in diastolic pressure despite preserved systolic ejection fraction. Diffuse systolic myocyte loss typically causes reduced EF and eccentric remodeling. Papillary muscle rupture produces acute severe mitral regurgitation, which is excluded by echocardiography. A right-to-left shunt causes hypoxemia rather than elevated left-sided filling pressure. Plaque rupture would suggest an acute coronary syndrome with ischemic systolic dysfunction, not this chronic nonobstructive presentation.

Reference: American College of Cardiology. Heart Failure in Women: Understanding the Differences to Change the Paradigm, section on HFpEF pathophysiology, 2024. https://www.acc.org/latest-in-cardiology/articles/2024/02/01/01/42/focus-on-heart-failure-heart-failure-in-women-understanding-the-differences-to-change-the-paradigm