Systolic heart failure vs Diastolic heart failure
How to tell Systolic heart failure and Diastolic heart failure apart when a board question makes them look alike.
Step 2 CK pairs are in open beta while clinical review finishes. Spot an issue? Tell us.
Ejection fraction on echocardiography is the fastest discriminator for systolic versus diastolic heart failure phenotype.
Side by side
Reduced left ventricular ejection fraction with dilated ventricle identifies systolic heart failure.
Preserved ejection fraction with impaired ventricular relaxation and elevated filling pressures identifies diastolic heart failure.
Myocardial contractile dysfunction reduces stroke volume and forward cardiac output.
Impaired ventricular compliance raises filling pressures despite preserved contractile fraction.
Systolic heart failure usually has LVEF <=40% on echocardiography, often with LV dilation and elevated natriuretic peptides such as BNP >100 pg/mL or NT-proBNP above age-adjusted thresholds.
Diastolic heart failure typically has LVEF >=50% with evidence of diastolic dysfunction, such as E/e' >14, left atrial enlargement, concentric LV hypertrophy, and elevated natriuretic peptide levels.
The trap
Dyspnea with edema is often treated identically without phenotype confirmation. The resolving clue is echo-defined ventricular function, because guideline-directed mortality-reducing drug choices are strongest in reduced EF disease.
The repair move
Next best step: confirm phenotype on echocardiography and begin guideline-directed therapy according to EF category. For symptomatic reduced EF, start loop diuretic for congestion and initiate foundational quadruple therapy as tolerated, including ARNI or ACE inhibitor, evidence-based beta blocker, mineralocorticoid receptor antagonist, and SGLT2 inhibitor. For preserved EF, prioritize diuresis for volume control, blood pressure optimization, and comorbidity management such as atrial fibrillation and obesity.
Try a free question
CoreA 72-year-old man with dyspnea has bilateral edema and pulmonary crackles. Echocardiography shows LVEF 30%. What is the most likely diagnosis?
Show answer and explanation
Answer: A. Systolic heart failure. LVEF of 30% defines heart failure with reduced ejection fraction, consistent with systolic heart failure.
Why the other choices are tempting
- B. Diastolic heart failure usually has preserved EF, often 50% or higher.
- C. Right ventricular infarction alone does not explain the defined reduced left ventricular EF phenotype.
- D. Constrictive physiology has different imaging findings and usually preserved systolic EF.
- E. Pulmonary embolism may cause dyspnea but does not directly define a chronic reduced LV EF syndrome.
Flashcards
Tap a card to flip it.
What echocardiographic threshold defines heart failure with reduced ejection fraction?
Left ventricular ejection fraction of 40% or lower defines reduced ejection fraction heart failure.
Which structural echo feature often accompanies diastolic heart failure with preserved EF?
Concentric LV hypertrophy with left atrial enlargement and elevated filling pressures is common.
Quick answers
What is the fastest way to tell Systolic heart failure from Diastolic heart failure?
Ejection fraction on echocardiography is the fastest discriminator for systolic versus diastolic heart failure phenotype.
What is the key clue for Systolic heart failure?
Reduced left ventricular ejection fraction with dilated ventricle identifies systolic heart failure.
What is the key clue for Diastolic heart failure?
Preserved ejection fraction with impaired ventricular relaxation and elevated filling pressures identifies diastolic heart failure.
What is the common trap with Systolic heart failure vs Diastolic heart failure?
Dyspnea with edema is often treated identically without phenotype confirmation. The resolving clue is echo-defined ventricular function, because guideline-directed mortality-reducing drug choices are strongest in reduced EF disease.