Abstract Body: Background: A restrictive mitral inflow pattern seen in Grade III diastolic dysfunction is frequently observed in patients with advanced cardiac remodeling. While often associated with restrictive cardiomyopathy (RCM), this pattern can also result from long-standing hypertensive heart disease (HHD). Differentiating between these two conditions is crucial as they have different etiologies, prognosis, and management pathways.
Objective: We aim to explore the diagnostic distinctions between restrictive filling patterns caused by hypertensive heart disease and restrictive cardiomyopathy by using comprehensive echocardiographic parameters and case-based analysis.
Methods: We reviewed transthoracic echocardiographic findings in an 85-year old elderly female with newly diagnosed heart failure with preserved ejection fraction (HFpEF). Parameters were evaluated, including LV mass index (LVMI), tissue Doppler e′ velocities, E/e′ ratio, LA volume index (LAVI), PASP, RV size/function, and global longitudinal strain. These findings were compared with RCM hallmark findings: severely reduced e′, apical sparing, biatrial enlargement, hepatic vein flow reversal, normal wall thickness, and pericardial effusion.
Results: The patient’s echocardiogram revealed a preserved left ventricular ejection fraction (59%) with moderate concentric left ventricular hypertrophy (LV mass index: 156.8 g/m2). Mitral inflow demonstrated a restrictive filling pattern with a markedly elevated E/A ratio of 3.29 and a medial E/e′ of 24.8, consistent with Grade III diastolic dysfunction. There was severe left atrial enlargement (LA volume index: 53.7 mL/m2) and an elevated pulmonary artery systolic pressure of 55 mmHg, accompanied by mild right ventricular dysfunction. Tissue Doppler velocities, although reduced, were not severely impaired, and global longitudinal strain was preserved without evidence of apical sparing. No pericardial effusion or features suggestive of infiltrative disease were present. Taken together with the clinical context of long-standing hypertension, these findings supported a diagnosis of restrictive filling secondary to hypertensive cardiac remodeling rather than a RCM.
Conclusion: Echocardiography is a key tool for differentiating restrictive filling patterns in diastolic dysfunction. Although findings were highly suggestive of hypertensive remodeling, further testing—such as cardiac MRI, 99mTc-PYP scan, or light chain analysis—may be warranted to definitively exclude RCM.