Heart Failure with Reduced Ejection Fraction vs Heart Failure with Preserved Ejection Fraction
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 — now has class I medical therapy.
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Side-by-side comparison
| Feature | Heart Failure with Reduced Ejection Fraction | Heart Failure with Preserved Ejection Fraction |
|---|---|---|
| At a glance | Systolic dysfunction with LVEF ≤40% — managed with 4-pillar GDMT. | HF symptoms with LVEF ≥50% from diastolic dysfunction — now has class I medical therapy. |
| Classic presentation | S3 gallop has high specificity for HF in adults; orthopnea correlates with elevated PCWP.; Dyspnea on exertion (early), orthopnea, paroxysmal nocturnal… | Indistinguishable from HFrEF clinically: DOE, orthopnea, PND, fatigue, edema; Symptoms may be more exertion-dependent early on (preserved resting CO); Atrial… |
| Workup / key labs | BNP or NT-proBNP (elevated; lower in obesity, higher in CKD/AFib/elderly); BMP (baseline Cr/K before starting ACEi/ARB/MRA), magnesium; LFTs (congestive… | H2FPEF score (heavy, hypertensive, AFib, pulmonary HTN, elder, filling pressure) — ≥6 makes HFpEF likely. EF cutoff ≥50% (40-49% = HFmrEF, mid-range).; BNP /… |
| Imaging | 12-lead ECG — look for prior MI (Q waves), LBBB (CRT candidate), AFib; CXR — cardiomegaly, cephalization, Kerley B lines, pleural effusions, pulmonary edema;… | 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… |
| First-line treatment | Four-pillar GDMT (start all 4 classes, typically titrated over weeks to target doses):; • ARNI (sacubitril-valsartan) — first-line. Alternatives if ARNI not… | SGLT2 inhibitor — dapagliflozin or empagliflozin; class I recommendation across full EF range (EMPEROR-Preserved, DELIVER); reduces HF hospitalization; Loop… |
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