Patient Profile
- Sex / Age:
- Female, 68 years
- Height / Weight:
- 162 cm / 80 kg (BMI 30.5; BSA 1.86 m²)
- Reported symptoms:
- Exertional dyspnea over 6 months, NYHA class II–III; lower-limb edema; nocturnal cough
- History:
- Long-standing hypertension (poorly controlled), atrial fibrillation (rate-controlled), type 2 diabetes
- Medications:
- Amlodipine, lisinopril, metformin, apixaban
- Study:
- Transthoracic echocardiography (TTE), comprehensive protocol
Summary Overview
Comprehensive TTE demonstrates concentric left ventricular hypertrophy with preserved ejection fraction (LVEF 60%), grade II diastolic dysfunction with elevated filling pressures, left atrial enlargement, and moderate functional mitral regurgitation. Estimated pulmonary artery systolic pressure 48 mmHg. Findings are most consistent with heart failure with preserved ejection fraction (HFpEF).
Key Hemodynamics & Indices
- LV mass index:
- 121 g/m² (concentric hypertrophy)
- Relative wall thickness (RWT):
- 0.49 (concentric pattern)
- E/e' (average septal-lateral):
- 16 (elevated; suggests increased LV filling pressures) [Nagueh SF, J Am Soc Echocardiogr 2016]
- Left atrial volume index:
- 42 mL/m² (enlarged)
- TR jet velocity:
- 3.2 m/s — PASP estimate ~48 mmHg
Detailed Imaging Findings
Synthesis
-
Heart failure with preserved ejection fraction (HFpEF)Highly Likely
Symptoms + concentric LVH + grade II diastolic dysfunction + LA enlargement + elevated E/e' + mild PH form a classic HFpEF profile [McDonagh TA, ESC HF Guidelines 2021/2023; Heidenreich PA, ACC/AHA 2022].
-
Hypertensive heart diseaseHighly Likely
Concentric remodeling with poorly controlled hypertension is the dominant etiology in this profile.
-
Cardiac amyloidosisConsider — atypical features
Increased wall thickness, low GLS, and HFpEF in older adults raise consideration; absent classic findings (apical sparing, granular myocardium, valve thickening pattern). Bone scintigraphy / MRI / serum free light chains can clarify if clinically suspected.
-
Functional mitral regurgitationModerate, Secondary
Likely secondary to LV remodeling and atrial dilatation; reassessment after HF optimization recommended.
Analytical Summary & Recommendations
Imaging impression
Concentric LVH with preserved EF, grade II diastolic dysfunction, LA enlargement, moderate functional MR, and mild pulmonary hypertension — consistent with HFpEF, most plausibly hypertensive in origin.
Recommended next steps
- Optimize blood pressure aggressively to target < 130/80 [Williams B, ESC/ESH 2018; Whelton PK, ACC/AHA 2017]
- SGLT2 inhibitor (e.g., empagliflozin or dapagliflozin) — improves outcomes in HFpEF [Anker SD, NEJM 2021; Solomon SD, NEJM 2022]
- Optimize diuretics for volume control; monitor renal function and electrolytes
- Continue anticoagulation (apixaban) for atrial fibrillation
- Cardiology referral for further heart failure phenotyping and longitudinal management
- Consider amyloid screening (bone scintigraphy ± serum free light chains) if clinical course or features suggest
- Lifestyle: weight reduction, sodium restriction, supervised exercise; manage diabetes
- Repeat TTE 6–12 months or sooner if symptoms change
Key Questions for Your Physician
- Should an SGLT2 inhibitor be added to my regimen given these findings?
- How should we tighten my blood-pressure control — target and timeline?
- Do I need any additional testing (BNP/NT-proBNP, amyloid screen)?
- How will my mitral regurgitation be monitored, and could it change with treatment?
- What signs of worsening should make me call urgently or come to the ED?
What This Means for You
Your echocardiogram shows that your heart is pumping well (the squeezing function — ejection fraction — is normal at 60%), but your left ventricle is thickened and is having trouble relaxing and filling properly. Your left atrium is enlarged. There is also moderate leaking at the mitral valve and a mildly elevated pulmonary pressure.
Together, these findings explain your shortness of breath and leg swelling — the diagnosis is heart failure with preserved ejection fraction (HFpEF). The most likely root cause is your long-standing high blood pressure, which makes the heart muscle thicken and stiffen over time.
The good news: HFpEF has effective modern treatments. Aggressive blood-pressure control (target < 130/80), addition of an SGLT2 inhibitor (a medication that improves heart failure outcomes), careful use of diuretics, weight reduction, and a structured exercise program can meaningfully improve symptoms and outcomes. Your atrial fibrillation continues to need anticoagulation (apixaban).
Seek urgent medical care for sudden severe shortness of breath, inability to lie flat, rapid weight gain, or new chest pain.
High confidence in chamber dimensions, function, and HFpEF classification. Etiology assessment benefits from clinical correlation and selective adjuncts (BNP/NT-proBNP, amyloid screen).
References
- McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (with 2023 focused update). Eur Heart J 2021;42(36):3599–3726.
- Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. JACC 2022;79(17):e263–e421.
- Anker SD, Butler J, Filippatos G, et al. Empagliflozin in Heart Failure with a Preserved Ejection Fraction. NEJM 2021;385(16):1451–1461.
- Solomon SD, McMurray JJV, Claggett B, et al. Dapagliflozin in Heart Failure with Mildly Reduced or Preserved Ejection Fraction. NEJM 2022;387(12):1089–1098.
- Nagueh SF, Smiseth OA, Appleton CP, et al. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography. J Am Soc Echocardiogr 2016;29(4):277–314.
- Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults. J Am Soc Echocardiogr 2015;28(1):1–39.