Clinical presentation

Patients with either systolic (HFrEF) or diastolic (HFpEF) HF usually present in the same way. Common signs and symptoms include the following: worsening fatigue; dyspnea on exertion, which may progress to dyspnea at rest; orthopnea; jugular venous distention; pedal edema; presence of a third or fourth heart sound; loss of appetite; and tachycardia. In some patients, hepatomegaly may also develop as the disease advances. Although dyspnea can be a manifestation of other clinical diagnoses, it is a very sensitive clinical feature of HF. 

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Distinguishing between systolic and diastolic HF is difficult if the distinction is based solely on the clinical presentation. Although the initial treatment for symptomatic heart failure is the same for either HFrEF or HFpEF, it is important to identify the underlying type because treatment approaches and maintenance therapy will vary based on the cause and type. 

Diagnostic workup

The diagnostic workup for HF is based largely on the clinical presentation and evidence of volume overload. A comprehensive health history and a thorough physical examination will help to rule out other causes of dyspnea. Diagnostic testing should include a basic metabolic panel, a complete blood cell count with differential, two-view chest radiography (posteroanterior and lateral), baseline electrocardiography, and transthoracic echocardiography (TTE). The echocardiogram is the gold standard for diagnosing HF and identifying the type. Additional testing includes transesophageal echocardiography (TEE) and a blood test for B-type natriuretic peptide (BNP). BNP is a protein that is released by the ventricles when they are stretched during volume overload6 and is a reliable indicator of volume overload. Because the test is relatively inexpensive and readily available, BNP is an easy marker to obtain, and its presence can contribute significantly to the diagnosis of HF.

Other specialized testing 

Other tests include coronary stress testing to rule out and/or correct ischemic causes that may be contributing to HF symptoms. Left heart catheterization (LHC) coronary angiography can be performed to study the coronary anatomy and provides the most accurate evaluation of ischemic vessels. Right heart catheterization (RHC) can also be performed to measure the internal pressures of the heart chambers. 

Treatment goals and options

The goals of treatment for HFrEF are to prevent hospitalization, preserve heart function, and improve the patient’s quality of life and survival. Strategies to achieve these goals are geared toward addressing patients’ self-care needs and medication adherence; early open discussion about implantable devices and initial discussions regarding advance directives are also included. 


Self-care is the most important (although difficult) strategy to implement and maintain. Having patients maintain a healthful lifestyle is highly effective but requires close monitoring and acceptance on their part. Addressing issues such as access, schedules, and work and family obligations can help to increase patient adherence. 

For exercise programs to be optimally effective, the duration of activity should range from 20 to 30 minutes on 5 days each week. Recent research has demonstrated that short bouts of moderately intense physical activity throughout the day are just as effective as a full 30 minutes of continuous exercise once daily.7 

Maintaining a low-sodium or no-added-salt diet is essential to reduce water retention. A moderate to high dietary intake of sodium is an independent risk factor for HF.8 Ideally, the total recommended daily sodium intake for a patient with HF is 1500 mg; however, because this is usually hard to achieve, the interim achievable goal is up to 2300 mg/d.9 

Every effort to support smoking cessation should be discussed, and alternatives must be offered at each encounter. Methods to increase compliance include constant encouragement in addition to open and frequent discussions. Praising the patient for every effort and including the family in medical visits are successful methods of increasing compliance.