How is heart failure categorized by ejection fraction and what are typical features of each category?

• A. HFrEF (LVEF ≤40-45%) with diastolic dysfunction; HFpEF (LVEF ≥50%) with systolic dysfunction
• B. HFrEF (LVEF ≤40-45%) with systolic dysfunction; HFpEF (LVEF ≥50%) with diastolic dysfunction
• C. HFrEF (LVEF ≥50%) with systolic dysfunction; HFpEF (LVEF ≤40-45%) with diastolic dysfunction
• D. HFrEF (LVEF ≤30%) with diastolic dysfunction; HFpEF (LVEF ≥60%) with mild diastolic dysfunction

Answer: (B)

Understanding how heart failure is categorized by ejection fraction means looking at how well the heart contracts (systolic function) versus how well it fills (diastolic function). When the ejection fraction is reduced, the heart isn’t pumping effectively because systolic contraction is weakened; this is heart failure with reduced ejection fraction, typically with an ejection fraction around 40% or less. The ventricle often becomes dilated and systolic performance is impaired, reflecting true systolic dysfunction.

If the ejection fraction is preserved, the pumping strength is still in the normal range, but the ventricle is stiff and doesn’t relax well during filling; this is heart failure with preserved ejection fraction, indicating diastolic dysfunction. In this scenario, filling pressures rise despite a normal or near-normal EF, and the usual structural change is concentric hypertrophy or a stiff ventricle rather than dilation.

So the best description is reduced EF with systolic dysfunction and preserved EF with diastolic dysfunction. In practice, remember that HFrEF tends to be linked to impaired contractility (often after myocardial injury) and HFpEF tends to be linked to impaired relaxation and filling (common with aging, hypertension, and LV hypertrophy). The other patterns—assigning diastolic dysfunction to a reduced EF category or using awkward thresholds like very low or very high EF—don’t fit the standard definitions.