Is systolic heart failure characterized by an ejection fraction of less than 40%, pulmonary congestion, cardiomegaly on chest x-ray, a decreased left ventricle, and an S3 gallop?

Characteristics of Systolic Heart Failure

Yes, systolic heart failure is characterized by an ejection fraction of less than 40%, pulmonary congestion with cardiomegaly on chest x-ray, decreased left ventricular function, and often an S3 gallop. 1

Diagnostic Criteria for Systolic Heart Failure

Systolic heart failure has specific diagnostic features that distinguish it from other forms of heart failure:

Ejection Fraction

• Ejection fraction less than 40% is the primary defining characteristic of systolic heart failure 1
• This contrasts with heart failure with preserved ejection fraction (HFpEF), which is defined by an LVEF ≥50% 2

Imaging Findings

• Chest X-ray findings:

  • Pulmonary congestion (venous or alveolar congestion, interstitial or pulmonary edema)
  • Pleural effusion
  • Cardiomegaly 1
  • Cephalization of venous flow 1

• Echocardiographic findings:

  • Reduced LV ejection fraction (<40%)
  • Reduced LV fractional shortening (<25%)
  • Increased LV end-diastolic size (diameter ≥60 mm, >32 mm/m², volume >97 mL/m²)
  • Increased LV end-systolic size (diameter >45 mm/>25 mm/m², volume >43 mL/m²) 1
  • Regional wall motion abnormalities (especially in ischemic heart failure) 1

Physical Examination Findings

• S3 gallop (third heart sound) - a hallmark finding in systolic heart failure 1
• Other common findings include:
  • Dyspnea with exertion or recumbency
  • Dependent edema
  • Rapid fatigue
  • Cough
  • Early satiety 1

Pathophysiology

Systolic heart failure represents impaired emptying of the left ventricle, manifested as:

• Decreased contractile function
• Ventricular dilation
• Reduced cardiac output 3
• Progressive pump failure, which is one of the most frequent causes of death 1

Distinguishing from Other Forms of Heart Failure

It's important to distinguish systolic heart failure from:

1. Heart Failure with Preserved Ejection Fraction (HFpEF):

   • HFpEF has EF ≥50% 2
   • Often presents with similar symptoms but different pathophysiology 4
   • More common in elderly women with systolic hypertension 4

2. Heart Failure with Mildly Reduced Ejection Fraction:

   • EF between 40-49% (falls between systolic heart failure and HFpEF)

Clinical Implications

The diagnosis of systolic heart failure has important treatment implications:

• Patients with systolic heart failure benefit from neurohormonal modulation therapies 5
• Accurate diagnosis guides therapy selection and prognosis assessment
• The presence of an S3 gallop and cardiomegaly on chest x-ray are important clinical markers that help confirm the diagnosis when combined with reduced ejection fraction 1

Common Pitfalls

• Relying solely on ejection fraction without considering other clinical and imaging findings
• Failing to recognize that systolic dysfunction is the most common cause of diastolic dysfunction and pulmonary congestion 3
• Not considering other causes of cardiomegaly and pulmonary congestion such as valvular disease

By accurately identifying these characteristic features of systolic heart failure, clinicians can make appropriate treatment decisions that impact morbidity and mortality outcomes.