Diastolic and Systolic Heart Failure Are Distinct Phenotypes Within the Heart Failure Spectrum

Heart failure (HF) is a major worldwide public health problem. One in 5 people aged 40 years in the United States will develop HF during his or her lifetime,1 and HF remains the leading cause for hospitalization among the elderly.2 Although age- and sex-specific HF incidence is not increasing,3 overall HF survival has improved, and the number of people aged >65 years is increasing rapidly. Thus, the absolute number of patients with HF will continue to increase. Half of the patients with HF have a preserved ejection fraction (HFpEF), and the remainder display reduced ejection fraction (HFrEF).4,–,6 The proportion of patients with normal ejection fraction (EF) is increasing steadily because of increased incidence and/or increasing physician recognition of the syndrome.4 Resource utilization associated with HF is high in both the inpatient and outpatient settings, regardless of EF. Response by De Keulenaer and Brutsaert on p 2014 Heart failure is a syndrome that can be defined clinically by a collection of symptoms (dyspnea, fatigue, exertional intolerance) and signs (edema, gallop, rales) that are attributable to a cardiac disorder.2 Heart failure may also be defined hemodynamically by an inability to provide adequate cardiac output to the body at rest or with exertion, or to do so only in the setting of elevated cardiac filling pressures. The cardiovascular system responds to a wide variety of insults (eg, myocardial disease, ischemia, valvular or pericardial disease) in a finite number of ways, both hemodynamically (elevated filling pressures, depressed output) and symptomatically (dyspnea, fatigue, angina). However, these similarities in clinical expression do not indicate that the underlying mechanisms of disease are the same or that treatment will be similar. For example, a headache may be noted with a migraine or brain tumor; dyspnea may be reported …