Adil Abbasi, MD FACP FACN

Learning Objectives

• Understand the pathophysiologic distinctions between systolic, diastolic, and mixed heart failure
• Classify heart failure using EF-based, symptomatic, etiologic, and age-based frameworks
• Apply evidence-based management strategies tailored to heart failure subtype and patient context
• Distinguish management priorities in asymptomatic vs symptomatic patients
• Integrate geriatric principles and comorbidity-driven care into heart failure management
• Develop practical, bedside-ready treatment strategies for complex real-world patients

Introduction

Heart failure (HF) is a heterogeneous clinical syndrome characterized by structural and/or functional cardiac abnormalities leading to impaired ventricular filling or ejection of blood. Contemporary management emphasizes phenotype-driven therapy, recognizing that outcomes improve when treatment is tailored to ejection fraction, symptom burden, etiology, and patient-specific factors such as age and comorbidities.

Traditional distinctions between “systolic” and “diastolic” heart failure have evolved into a more nuanced classification based on left ventricular ejection fraction (LVEF), with additional overlay of clinical stage and functional status. Importantly, most patients—especially older adults—have overlapping systolic and diastolic dysfunction, necessitating integrated management strategies.

Core Pathophysiologic Phenotypes

1. Systolic Heart Failure (HFrEF)

Defined by reduced contractility and impaired forward flow, typically with LVEF ≤40%. Common etiologies include ischemic cardiomyopathy, dilated cardiomyopathy, and myocarditis. Neurohormonal activation (RAAS and sympathetic systems) plays a dominant role, making these pathways key therapeutic targets.

2. Diastolic Heart Failure (HFpEF)

Characterized by impaired ventricular relaxation and increased stiffness, with preserved EF (≥50%). Filling pressures are elevated despite normal systolic function. Frequently associated with aging, hypertension, diabetes, obesity, and atrial fibrillation.

3. HF with Mildly Reduced EF (HFmrEF)

LVEF 41–49%, representing an intermediate phenotype with features of both systolic and diastolic dysfunction. Increasing evidence supports partial responsiveness to therapies proven in HFrEF.

4. Combined Systolic + Diastolic Dysfunction

Common in elderly patients and those with long-standing cardiovascular disease. These patients often exhibit:

• Reduced EF
• Impaired relaxation
• Elevated filling pressures

This group requires blended management strategies targeting both contractility and filling abnormalities.

Clinical Classification Framework

1.Ejection Fraction (EF) based classification

Table 1. EF-Based Classification and Therapeutic Implications

2. Symptom-Based Classification: New York Heart Association Functional Classification

3. Stage-Based Classification: ACC/AHA Heart Failure Stages

4. Etiology-Based Management

Table 2. Cause-Specific Considerations

Management by Clinical Presentation

I. Asymptomatic Heart Failure (Stage B)

Patients with structural heart disease but no symptoms.

Goals

• Prevent progression
• Reverse remodeling
• Reduce mortality

Management

• ACE inhibitors (e.g., Lisinopril)
• Beta-blockers (e.g., Metoprolol)
• Statins (if ischemic disease)
• Aggressive BP control

II. Symptomatic Heart Failure (Stage C)

II A. HFrEF (EF ≤40%)

Four Pillars of GDMT:

Additional:

• Loop diuretics for congestion (Furosemide)
• Hydralazine/nitrates in selected populations

II B. HFpEF (EF ≥50%)

No single mortality-reducing therapy; focus is on multidimensional management:

• SGLT2 inhibitors (Empagliflozin)
• Diuretics for congestion
• Control of:

• Hypertension
• Atrial fibrillation
• Diabetes
• Obesity

II C. HFmrEF (EF 41–49%)

• Treat similarly to HFrEF when tolerated
• Strongest evidence:

• SGLT2 inhibitors
• Beta-blockers
• ACEi/ARB/ARNI (selectively)

III. Acute Decompensated Heart Failure

Presentation

• Dyspnea
• Edema
• Pulmonary congestion

Management

• IV diuretics (Furosemide)
• Oxygen
• Treat precipitating cause (infection, arrhythmia)

Age-Based Management Considerations

Younger Patients (<65 years)

• Aggressive GDMT
• Device therapy (ICD/CRT)
• Advanced therapies (LVAD, transplant)

Older Adults (>75 years)

• High prevalence of HFpEF and mixed HF
• Increased sensitivity to:

• Hypotension
• Renal dysfunction
• Polypharmacy

Principles

• “Start low, go slow”
• Prioritize symptom control
• Avoid over-treatment

Frail / Advanced Dementia Patients

• Focus on:

• Comfort
• Minimizing hospitalizations
• Reducing medication burden

Often appropriate to:

• Use only diuretics ± beta-blocker
• Avoid aggressive GDMT escalation

Integrated Management Strategy

Table 3. Practical Bedside Approach

Concept Check Questions

Question 1: A 78-year-old with EF 55%, hypertension, and AF presents with edema. Best management?

Answer: HFpEF → treat congestion (diuretics), control BP and AF, consider SGLT2 inhibitor.

Question 2: Which HF type has strongest evidence for mortality reduction?

Answer: HFrEF → full GDMT reduces mortality significantly.

Question 3: Why are pulmonary vasodilators avoided in HF-related pulmonary hypertension?

Answer: They worsen ventilation-perfusion mismatch and do not improve outcomes in Group 2 PH.

Outcome-Based Benefits of Heart Failure Therapies

Table 4: Evidence-Based Impact of Therapies Across HF Types

Phenotype-Specific Benefit Summary

Clinical Interpretation (Key Insights)

1. Mortality Reduction (Most Powerful)

• ARNI
• Beta-blockers
• MRA
• ICD/CRT (devices)

These define true disease-modifying therapy in HFrEF

2. Hospitalization Reduction (Across All EF Types)

• SGLT2 inhibitors (most consistent across EF spectrum)
• ARNI
• Beta-blockers

3. Symptom Relief (Immediate Impact)

• Loop diuretics (most effective)
• SGLT2 inhibitors (moderate)
• CRT (in selected patients)

4. HFpEF Reality Check

• No strong mortality-reducing therapy
• Best intervention:

• SGLT2 inhibitors 
• Aggressive comorbidity management

5. Elderly / Frail Patients (Critical Insight)

• Mortality benefit may be less relevant than:

• Symptom control
• Avoiding hypotension/AKI

• Often appropriate:

• Diuretics ± beta-blocker
• Avoid full GDMT escalation

Quick Bedside Takeaway

Summary

• Heart failure is best managed using multidimensional classification (EF, symptoms, stage, etiology, age)
• HFrEF → strong evidence for mortality reduction with GDMT
• HFpEF → focus on comorbidities and symptom control
• HFmrEF → intermediate, treat selectively
• Elderly/frail patients → prioritize quality of life ad avoid polypharmacy
• Treatment must be individualized, not protocol-driven 

References

• Heidenreich PA et al. (2022). 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. Circulation
• McDonagh TA et al. (2021). ESC Guidelines for Heart Failure. European Heart Journal
• Anker SD et al. (2021). Empagliflozin in Heart Failure with Preserved EF. NEJM
• Packer M et al. (2020). SGLT2 inhibitors in HF. Circulation
• Yancy CW et al. (2017). ACC/AHA HF Guidelines Update. Journal of the American College of Cardiology