Echocardiography core measures — practice case: breathlessness, AF and a preserved LVEF

Presentation

Practice case (not a real patient). A 76-year-old woman in Brisbane has symptoms and signs of HF, and HF is suspected. She has persistent atrial fibrillation. Her NT-proBNP is raised.^[1] Transthoracic echocardiography shows an LVEF of 60%; an echocardiogram two years ago showed an LVEF of 62%, and her LVEF has never been below 50%. Her LV mass index is 102 g/m² with a relative wall thickness of 0.45, her LA volume index 46 mL/m², her E/e′ at rest 12, her septal e′ 6 cm/s and her TR velocity at rest 3.0 m/s.^[1][10] There is no septal flattening, the RV/LV basal diameter ratio is 0.8, the IVC measures 18 mm with normal collapse and the RA area is 16 cm².^[4]

Step 1 — Why echocardiography?

• ESC 2026 HF recommends a transthoracic echocardiogram in patients with suspected HF to confirm the diagnosis, differentiate between HF phenotypes and aid in identifying the underlying aetiology of HF (Class I, Level C).^[1]
• AHA/ACC 2022 says TTE should be performed during initial evaluation in patients with suspected or newly diagnosed HF to assess cardiac structure and function (COR 1, LOE C-LD).^[2]

Step 2 — Which phenotype under ESC 2026 HF?

• She has symptoms and signs of HF and an LVEF ≥50% that has not previously been <50%, so two of the three ESC 2026 HFpEF criteria are met.^[1]
• ESC 2026 HF Table 10 (simplified echocardiographic criteria supporting objective evidence of HFpEF): LV mass index 102 g/m² meets the female threshold of ≥95 g/m² (and RWT 0.45 is >0.42); LA volume index 46 mL/m² meets the AF threshold of >40 mL/m²; E/e′ 12 meets >9 at rest; TR velocity 3.0 m/s meets >2.8 m/s.^[1]
• All four parameters are in the pathological range, and ESC 2026 HF says the probability of HFpEF increases with that number.^[1]
• ESC 2026 HF says testing for elevated natriuretic peptides may in most patients support the diagnosis of HFpEF, but that diagnostic thresholds for HFpEF should be critically evaluated based on patient characteristics, especially with obesity and other factors that may reduce natriuretic peptide levels; her raised level may support the third criterion.^[1]
• Its Table 9 lists advanced age and atrial fibrillation among causes for increased natriuretic peptide levels, and clinicians must consider these factors with clinical assessment and investigation findings when interpreting the result.^[1]

Step 3 — Do the other guidelines agree?

• AHA/ACC 2022 Appendix 3: her LAVI meets ≥29 mL/m², her RWT meets >0.42, her septal e′ of 6 cm/s meets <7 cm/s and her TR velocity meets >2.8 m/s, but her E/e′ of 12 does not reach the suggested average E/e′ ≥15.^[2]
• NHFA/CSANZ 2018 counts echocardiographic high filling pressure when at least three of four criteria are met: her septal e′ of 6 cm/s (<7 cm/s), LA volume index of 46 mL/m² (>34 mL/m²) and TR velocity of 3.0 m/s (>2.8 m/s) make three, while her E/e′ of 12 does not exceed 14.^[10]

Step 4 — Is there pulmonary hypertension?

• ESC/ERS 2022 says a peak TRV >2.8 m/s may suggest PH, but TRV alone cannot reliably determine whether PH is present, and echocardiography alone cannot confirm PH, which requires RHC.^[4]
• None of her reported measurements is an ESC/ERS 2022 Table 10 sign: RV/LV basal ratio 0.8 (threshold >1.0), no septal flattening, IVC 18 mm with normal collapse (threshold >21 mm with decreased collapse) and RA area 16 cm² (threshold >18 cm²).^[4]
• In ESC/ERS 2022 Table 23, the PH-LHD likely echocardiography cell includes LA dilation (LAVI >34 mL/m²) and LVH; her age over 70 and persistent AF are also in that column.^[4]
• Based on the probability of PH by echocardiography, further testing should be considered in the clinical context, i.e. symptoms and risk factors or associated conditions for PAH/CTEPH (ESC/ERS 2022, Class IIa, Level B).^[5]
• Management of HFpEF is covered in the HFpEF topic, and of pulmonary hypertension in the pulmonary hypertension topic.

Marking (Pass/Fail)

• Pass: states the ESC 2026 HF Class I echocardiography row; applies all three HFpEF criteria, including that LVEF has never been <50%; uses the AF threshold for LA volume; names the AHA/ACC 2022 and NHFA/CSANZ 2018 thresholds without blending them; and says echocardiography cannot confirm PH.^{[1][2][10][4]}
• Fail: uses the sinus-rhythm LA threshold in AF, mixes thresholds from different guidelines, or diagnoses PH from the TR velocity alone.^[1][4]