Definition: CHF w/ preserved systolic function (EF>40%) w/o other identifiable cause.


Etiologies: impaired relaxation and/or impaired distensibility of LV

1.   LVH- HTN, HCMP, LV outflow obstruction (AS, IHSS)

2.   Restrictive CMP

a.            infiltrative- amyloid, sarcoid, hemochromatosis, transplant rejection

b.            endocardial- fibroelastosis, fibrosis

c.   DM

d.            idiopathic

1.   Aging- “presbycardia”

2.   Obesity

3.      Abbreviated LV filling- sustained tachycardia, AF

4.   Idiopathic


Differential diagnosis for CHF w/ normal LV systolic fxn:

1.   Incorrect dx: not CHF

2.   Reversible systolic dysfunction: HTN-related pulmonary edema, ischemia, peripartum CMP, EtOH CMP, tachycardia CMP, selenium or carnitine deficiency, infection, drugs.

3.   RHF: pulmHTN, pulm stenosis, TV disease, RV CMP, RV infarction, RA myxoma, intracardiac shunt.

4.   LA HTN: mitral stenosis or regurgitation, LA myxoma, pulm venous obstruction, high-output heart failure (thyrotoxicosis, AVF, beri-beri).

5.   Non-cardiogenic pulmonary edema: constrictive pericarditis, tamponade


Clinical features and diagnosis:

1.   H & P- 4 most reliable signs of CHF: 1) pulsus alternans, 2) reduced proportional pulse pressure ([SBP-DBP]/SBP < 0.25), 3) abnormal BP response to Valsalva, 4) JVD.  NONE can differentiate systolic from diastolic dysfunction.

2.   EKG: not useful to distinguish systolic from diastolic dysfunction.

3.   CXR: enlarged cardiac silhouette more common in systolic dysfunction.

4.   ECHO



Treatment: reverse what is reversible.





   acute ischemia

anti-ischemic agents, revascularization

   post-infarction scar or


ACEI, rx residual ischemia


lower BP


negative inotropes (CCB, beta-blockers), dual chamber PM, myomectomy

Restrictive CMP

rx reversible factors (avoid dig and beta-blockers in amyloid)

Valvular disease

surgery +/- diuretics, afterload reduction


Ramachandran et al. Arch Int Med. 156: 146-157, 1996.