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← Section VI · Miscellaneous Topics (Role of Echo)
VI.A

Heart Failure

7 cards

Notes

Heart failure phenotypes

  • HFrEF (reduced EF): LVEF ≤ 40 %.
  • HFmrEF (mid-range EF): LVEF 41–49 %.
  • HFpEF (preserved EF): LVEF ≥ 50 % with elevated filling pressures.
  • HFimpEF (improved EF): baseline < 40 %, now > 40 % on therapy.

Key echo assessment

  • LV size, EF, GLS.
  • LV geometry (concentric hypertrophy / remodeling / eccentric).
  • Diastolic function (Nagueh 2016 algorithm).
  • RV size and function (TAPSE, RV S′, FAC).
  • Atrial size (LAVI, RA area).
  • Pulmonary artery pressure (TR-derived PASP, PA AT).
  • Valvular pathology (contributing MR / TR / AR).
  • IVC / RA pressure.
  • Pericardium.

HFpEF echo criteria

  • LVEF ≥ 50 %, evidence of elevated filling pressures on either invasive testing or a combination of:
    • LAVI > 34 mL/m².
    • E/e′ > 14.
    • Septal e′ < 7 cm/s (lateral < 10).
    • TR peak velocity > 2.8 m/s.
    • Estimated PASP > 35 mmHg.
  • H2FPEF score and HFA-PEFF score integrate echo + clinical features to formalize diagnosis.

Cardiac amyloid - recognize in HFpEF

  • Concentric LVH with thickened walls (≥ 12 mm).
  • Low ECG voltage (voltage-mass mismatch).
  • Bi-atrial enlargement.
  • Small pericardial effusion.
  • Apical-sparing GLS pattern (cherry-on-top).
  • Confirm with PYP scan (ATTR) or serum/urine immunofixation (AL).

Prognostic echo parameters in HF

  • Reduced GLS (less negative than −14 % - strong prognostic marker).
  • Low e′ velocity, high E/e′.
  • Enlarged LA (LAVI > 45 mL/m²).
  • Restrictive mitral inflow pattern.
  • Reduced TAPSE, high PASP, low right heart function.
  • Functional MR (secondary MR).

Response to therapy

  • Reverse remodeling: reduction in LVESV ≥ 15 % suggests favorable response (e.g., to GDMT or CRT).
  • Improvement in EF ≥ 10 % or normalization to > 40 % is "improved EF" phenotype.

Common echocardiographic drivers of HF exacerbations

  • Worsening MR (functional).
  • Progressive AS or AR.
  • Reduced diastolic function with new AF.
  • Constrictive physiology (post-radiation, post-cardiotomy).

Cards

  • basicVI.A-001
    Define HFrEF, HFmrEF, HFpEF, HFimpEF by LVEF.
    → HFrEF: LVEF ≤ 40%. HFmrEF: 41–49%. HFpEF: ≥ 50% (with elevated filling pressures). HFimpEF: baseline < 40%, now > 40% on therapy.
  • basicVI.A-002
    List four echo criteria that support elevated LV filling pressure in suspected HFpEF.
    → 1) LAVI > 34 mL/m². 2) Average E/e′ > 14 (or septal > 15). 3) Septal e′ < 7 or lateral e′ < 10 cm/s. 4) TR peak velocity > 2.8 m/s (elevated PASP). Also estimated PASP > 35 mmHg.
  • basicVI.A-003
    What imaging finding on echo strongly suggests cardiac amyloidosis in a patient with HFpEF?
    → Apical-sparing GLS pattern ('cherry-on-top' bull's-eye) in a patient with concentric LVH. Also look for voltage-mass mismatch on ECG, biatrial enlargement, thickened valves, and small pericardial effusion.
  • basicVI.A-004
    What GLS threshold is prognostic in heart failure?
    → A GLS less negative than −14% (i.e., worse than −14%) predicts worse outcomes in HFrEF and HFpEF.
  • basicVI.A-005
    What quantitative echo change defines 'reverse remodeling' after HF therapy or CRT?
    → Reduction in LV end-systolic volume ≥ 15% at 6 months.
  • basicVI.A-006
    What confirmatory tests distinguish ATTR from AL cardiac amyloid?
    → Serum/urine immunofixation + free light chain assay to exclude AL. If negative, technetium-99m pyrophosphate (PYP) scan with grade 2–3 uptake diagnoses ATTR without biopsy.
  • basicVI.A-007
    Which valvular pathology is a common contributor to acute decompensation in HFrEF?
    → Functional (secondary) mitral regurgitation — from LV dilation and papillary muscle displacement causing leaflet tethering.