Causes of Systolic and Diastolic Heart Failure
Systolic heart failure (HFrEF) is predominantly caused by coronary artery disease and myocardial infarction (approximately two-thirds of cases), while diastolic heart failure (HFpEF) is primarily driven by hypertension, with myocardial infarction being notably less common. 1, 2
Systolic Heart Failure (HFrEF) - Primary Causes
The most common causes of systolic dysfunction include:
Ischemic Causes
- Coronary artery disease with myocardial infarction - accounts for ~67% of systolic HF cases 1
- Chronic myocardial ischemia without infarction
Non-Ischemic Causes
- Hypertension - particularly when inadequately controlled over time 2
- Dilated cardiomyopathy - up to 30% may have genetic causes 3
- Viral myocarditis - recognized or unrecognized infection 1
- Cardiotoxic agents:
- Anthracyclines (doxorubicin)
- Trastuzumab
- Alcohol abuse 1
- Tachycardia-induced cardiomyopathy - sustained inappropriate tachycardia 2
- Valvular heart disease - particularly chronic volume overload 2
- Peripartum cardiomyopathy 2
- Infiltrative diseases - amyloidosis, sarcoidosis, hemochromatosis 3
- Endocrine/metabolic disorders - diabetes mellitus, thyroid disease 2
- Nutritional deficiencies 4
- Autoimmune disorders - systemic lupus erythematosus 4
Diastolic Heart Failure (HFpEF) - Primary Causes
The vast majority of HFpEF patients have a history of hypertension, with most showing left ventricular hypertrophy on echocardiography. 3
Primary Drivers
- Hypertension - present in the overwhelming majority of cases, at least as common as in HFrEF 3
- Aging-related changes - decreased elastic properties of heart and vessels, increased myocardial stiffness, structural fibrosis 3
- Diabetes mellitus - frequently coexists with hypertension 3
Structural Cardiac Disorders
- Restrictive cardiomyopathy 3
- Hypertrophic cardiomyopathy - obstructive and non-obstructive forms 3
- Infiltrative cardiomyopathies:
- Amyloidosis
- Sarcoidosis
- Hemochromatosis 3
- Pericardial constriction 3
Contributing Conditions
- Atrial fibrillation - loss of atrial kick significantly impairs ventricular filling 3
- Coronary artery disease - less common than in HFrEF but still present 3
- Aortic stenosis - adversely affects diastolic properties 3
- Obesity - decreases time available for ventricular filling 3
Key Distinguishing Features
HFpEF is most prevalent among elderly women with hypertension and diabetes, whereas HFrEF shows no strong sex predominance and is more commonly associated with prior myocardial infarction. 3
Epidemiologic Differences
- HFpEF patients: Older, more often female, higher rates of obesity, hypertension, and atrial fibrillation 1
- HFrEF patients: More likely to have coronary artery disease and prior MI 3, 1
Pathophysiologic Mechanisms
In HFpEF, aging has a greater impact on ventricular filling characteristics than on ejection fraction 3:
- Decreased elastic properties of heart and great vessels
- Increased systolic blood pressure and myocardial stiffness
- Structural changes from fibrosis
- Decline in relaxation and compliance
- Decreased beta-adrenergic receptor density
- Reduced peripheral vasodilator capacity
Sex-specific responses exist: Women appear more susceptible than men to cumulative effects of aging, hypertension, and diabetes on diastolic function 3
Clinical Pitfalls
Don't assume normal EF excludes significant cardiac pathology - most HFpEF patients have detectable structural abnormalities including LVH, atrial dilation, mitral annular calcification, or myocardial scar 3
Consider the differential diagnosis in HFpEF - exclude primary valvular disease, high-output states (anemia, thyrotoxicosis), chronic pulmonary disease, and inaccurate LVEF measurement 3
Recognize that diastolic dysfunction occurs in both HFrEF and HFpEF - abnormal diastolic function is present in patients with reduced LVEF as well 3
Multiple comorbidities frequently coexist - particularly in elderly patients, making attribution of causality challenging 3, 2