A 55-year-old woman has exertional dyspnea with preserved LVEF (60%). Echo shows concentric LV hypertrophy, left atrial enlargement, and E/e' ratio of 18. NT-proBNP is elevated. Which hemodynamic finding best supports the diagnosis of heart failure with preserved ejection fraction?

• A Normal filling pressures at rest and exercise
• B Reduced cardiac index with dilated LV cavity
• C Elevated LV end-diastolic volume with reduced wall thickness
• D Elevated pulmonary capillary wedge pressure with normal LV end-diastolic volume ✓

Explanation

HFpEF is defined by symptoms and signs of heart failure with EF above 50%, elevated filling pressures (PCWP above 15 mmHg at rest or above 25 mmHg with exercise), and a small, stiff, non-dilated LV with concentric remodeling. An E/e' ratio above 14 on echo reflects elevated LV filling pressure non-invasively. Dilated cavities and reduced wall thickness suggest HFrEF, and normal filling pressures exclude the diagnosis.

Reference: Braunwald's Heart Disease, 12th ed.

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