Systolic and diastolic heart failure--diagnostic and therapeutic dilemmas

Clinical suspicion of congestive heart failure (CHF) always requires a careful diagnostic workup. This comprises the verification of the presence of CHF (in contrast to other conditions that cause nonspecific phenomena such as shortness of breath and edema), evaluation of the underlying cause of heart failure, and assessment of left ventricular (LV) systolic function. In addition to clinical examination, echocardiography is warranted in most cases. On the basis of this information, patients can be selected for further studies, such as exercise testing, cardiac catheterization and coronary angiography. In view of the serious prognosis of heart failure, especially systolic CHF, the threshold for specialist consultation should be low. Although the classification of CHF into systolic and diastolic forms is complex, clinically meaningful data can be derived simply by determining whether LV systolic function is impaired (predominantly systolic CHF) or not (probable diastolic CHF). In the latter case, treatment is mainly symptomatic in addition to the management of the underlying condition (e.g. hypertension). In systolic CHF, considerable therapeutic advances have recently been made and it is important that patients receive appropriate care to improve their prognosis. These measures include angiotensin-converting enzyme inhibitors, beta-blockers and spironolactone.