Confusable diagnoses · PANCE / PANRE

Heart Failure with Reduced Ejection Fraction vs Heart Failure with Preserved Ejection Fraction

Written & clinically reviewed by Ryan Busch, PA-C · Updated August 2026 · Report an error

Heart Failure with Reduced Ejection Fraction and Heart Failure with Preserved Ejection Fraction are easy to mix up on the boards. Here's a side-by-side comparison — presentation, workup, imaging, and first-line treatment — drawn from our full outlines.

Heart Failure with Reduced Ejection Fraction vs Heart Failure with Preserved Ejection Fraction at a glance

  • Heart Failure with Reduced Ejection Fraction: Systolic dysfunction with LVEF ≤40% — managed with 4-pillar GDMT.
  • Heart Failure with Preserved Ejection Fraction: HF symptoms with LVEF ≥50% from diastolic dysfunction — SGLT2i and MRAs reduce HF hospitalization; no therapy has a proven mortality benefit.

Try two board-style questions on Heart Failure with Reduced Ejection Fraction vs Heart Failure with Preserved Ejection Fraction

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Question 1CardiovascularMedium
A 65-year-old man with ischemic cardiomyopathy is seen for routine follow-up. Two years ago his ejection fraction was 25 percent with a left bundle branch block and QRS duration of 158 ms, and he received a cardiac resynchronization therapy defibrillator (CRT-D). He has remained on quadruple guideline-directed medical therapy with sacubitril-valsartan, carvedilol, spironolactone, and dapagliflozin. He is now asymptomatic at New York Heart Association class I, and a repeat echocardiogram shows that his ejection fraction has improved to 48 percent. Which of the following is the most appropriate management of his device and medications?
  • AContinue the CRT-D and current four-drug regimen
  • BRemove the CRT-D and continue the four-drug regimen
  • CReprogram the CRT-D to standard right ventricular pacing
  • DDiscontinue sacubitril-valsartan and the beta-blocker
Reveal answer & full explanation
Correct answer: A — Continue the CRT-D and current four-drug regimen
  • AContinue the CRT-D and current four-drug regimen✓
  • BRemove the CRT-D and continue the four-drug regimen
  • CReprogram the CRT-D to standard right ventricular pacing
  • DDiscontinue sacubitril-valsartan and the beta-blocker

Why Continue the CRT-D and current four-drug regimen is correct

  • This patient has heart failure with improved ejection fraction (HFimpEF; prior LVEF ≤40% now >40%): improvement from 25% to 48% is the result of ongoing resynchronization and guideline-directed medical therapy (GDMT), not a cure of the underlying cardiomyopathy
  • The improved ejection fraction is device- and medication-dependent, so the entire treatment regimen must be maintained indefinitely
  • In the TRED-HF withdrawal trial (recovered dilated cardiomyopathy), 44% of patients relapsed within 6 months of stopping heart failure medications, and the 2022 AHA/ACC/HFSA guideline recommends continuing GDMT in HFimpEF
  • Annual echocardiographic surveillance is appropriate, but no de-escalation is indicated

Why the others are wrong

  • Remove the CRT-D and continue the four-drug regimen — the recovery itself depends on resynchronization; explanting the device predictably leads to deterioration, and the defibrillator also continues to provide primary prevention against sudden death in ischemic cardiomyopathy
  • Reprogram the CRT-D to standard right ventricular pacing — right ventricular-only pacing produces dyssynchrony and would abolish the resynchronization benefit, again risking relapse
  • Discontinue sacubitril-valsartan and the beta-blocker — these agents are foundational pillars of GDMT; stopping them removes the neurohormonal blockade responsible for sustaining the improved ejection fraction and is a leading cause of recurrent heart failure in recovered patients
Question 2CardiovascularMedium
A 76-year-old woman presents with exertional chest pressure and dyspnea. She has no prior cardiac history. Echo shows ejection fraction (EF) 62% with concentric left ventricular (LV) hypertrophy, impaired relaxation, and elevated filling pressures. BNP is 420 pg/mL. Which is the most likely diagnosis?
  • AHeart failure with preserved ejection fraction (HFpEF)
  • BHypertrophic cardiomyopathy
  • CRestrictive cardiomyopathy
  • DConstrictive pericarditis
Reveal answer & full explanation
Correct answer: A — Heart failure with preserved ejection fraction (HFpEF)
  • AHeart failure with preserved ejection fraction (HFpEF)✓
  • BHypertrophic cardiomyopathy
  • CRestrictive cardiomyopathy
  • DConstrictive pericarditis

Why heart failure with preserved ejection fraction (HFpEF) is correct

  • HFpEF is defined by ejection fraction (EF) 50% or higher and is characterized by diastolic dysfunction
  • Impaired left ventricular (LV) relaxation produces elevated filling pressures despite preserved systolic function
  • Concentric left ventricular hypertrophy (LVH) from chronic hypertension is the most common cause
  • Treatment focuses on symptom management with diuretics for congestion, aggressive blood pressure control, and rate control if atrial fibrillation (AF) is present
  • Unlike heart failure with reduced ejection fraction (HFrEF), no therapy specifically reduces mortality in HFpEF

Why the others are wrong

  • Hypertrophic cardiomyopathy — produces asymmetric septal hypertrophy, often with dynamic left ventricular outflow tract obstruction and a murmur that augments with Valsalva, and typically presents earlier in life; this echo shows symmetric concentric hypertrophy without outflow obstruction
  • Restrictive cardiomyopathy — shows marked biatrial enlargement with minimal LVH and restrictive physiology on catheterization, differing from the concentric LVH pattern seen here
  • Constrictive pericarditis — also raises filling pressures with a preserved EF, but through a thickened, non-compliant pericardium with ventricular interdependence, septal bounce, and a pericardial knock, with normal wall thickness rather than concentric LVH
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Side-by-side comparison

FeatureHeart Failure with Reduced Ejection FractionHeart Failure with Preserved Ejection Fraction
At a glanceSystolic dysfunction with LVEF ≤40% — managed with 4-pillar GDMT.HF symptoms with LVEF ≥50% from diastolic dysfunction — SGLT2i and MRAs reduce HF hospitalization; no therapy has a proven mortality benefit.
Classic presentationS3 gallop has high specificity for HF in adults; orthopnea correlates with elevated PCWP.; Dyspnea on exertion (early), orthopnea, paroxysmal nocturnal dyspnea (PND); Fatigue, exercise intolerance; Lower extremity edema, abdominal bloating, early satiety (right HF); Nocturia (fluid redistribution when supine); JVD (JVP >3 cm above the…Indistinguishable from HFrEF clinically: DOE, orthopnea, PND, fatigue, edema; Symptoms may be more exertion-dependent early on (preserved resting CO); Atrial fibrillation often unmasks symptoms (loss of atrial kick); Similar to HFrEF: JVD, crackles, S4 gallop (vs S3 in HFrEF — stiff ventricle accentuates A wave); Hypertension on exam…
Workup / key labsBNP or NT-proBNP (elevated; lower in obesity, higher in CKD/AFib/elderly); BMP (baseline Cr/K before starting ACEi/ARB/MRA), magnesium; LFTs (congestive hepatopathy); CBC, TSH, iron studies, A1c; Lipid panel; consider screening for HIV, hemochromatosis, amyloid (in select cases)H2FPEF score (heavy, hypertensive, AFib, pulmonary HTN, elder, filling pressure) — ≥6 makes HFpEF likely. EF cutoff ≥50% (41-49% = HFmrEF, heart failure with mildly reduced EF).; BNP / NT-proBNP — elevated, though may be lower than in HFrEF for same severity (especially in obesity); CBC, BMP, TSH, A1c, lipid panel; Cardiac amyloid…
Imaging12-lead ECG — look for prior MI (Q waves), LBBB (CRT candidate), AFib; CXR — cardiomegaly, cephalization, Kerley B lines, pleural effusions, pulmonary edema; Transthoracic echo — measures LVEF, chamber sizes, wall motion, valve function, RV size/function, pulmonary pressures; Coronary angiography or CT coronary angiography if ischemic…TTE: LVEF ≥50% with diastolic dysfunction parameters (E/e' >14, LA dilation >34 mL/m², elevated PASP, abnormal mitral inflow patterns); Stress echo can unmask exercise-induced diastolic dysfunction; Cardiac MRI if amyloid or HCM suspected
First-line treatmentFour-pillar GDMT (start all 4 classes, typically titrated over weeks to target doses):; • ARNI (angiotensin receptor–neprilysin inhibitor, sacubitril-valsartan: sacubitril blocks neprilysin, raising natriuretic peptides and bradykinin; valsartan blocks AT1 receptors) — first-line. Alternatives if ARNI not feasible: ACEi (lisinopril,…SGLT2 inhibitor — dapagliflozin or empagliflozin; class 2a in the 2022 AHA/ACC/HFSA guideline (class I in the 2023 ESC focused update); reduces HF hospitalization without a proven mortality benefit (EMPEROR-Preserved, DELIVER); Loop diuretic for volume overload — furosemide, torsemide, or bumetanide; titrated to symptom relief; avoid…

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Full outlines

Heart Failure with Reduced Ejection Fraction (HFrEF) Heart Failure with Preserved Ejection Fraction (HFpEF) All 514 diagnoses

Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.