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The diagnosis of heart failure is not always easy. It is even more difficult for the group of patients who have symptoms of heart failure but are found to have a normal left ventricular ejection fraction (LVEF), a condition variously called diastolic heart failure, heart failure with preserved ejection fraction or more precisely heart failure with a normal ejection fraction (HFNEF).1 2 Most patients presenting to a hospital emergency department with heart failure will have obvious classic diagnostic symptoms and signs such as peripheral oedema, raised jugular venous pressure and a third heart sound, and echocardiography will confirm a dilated left ventricle and reduced ejection fraction. These patients with ‘systolic heart failure’ or more accurately heart failure with reduced ejection fraction (HFREF) are simpler to recognise and treatment with inhibitors of the rennin-angiotensin-aldosterone system and β-blockers is well established and supported by large clinical trials. For the HFNEF group, however, the situation is completely different. Although presentation with HFNEF can be acute with obvious pulmonary oedema often it is a complaint of breathlessness on exertion that prompts the referral to a clinic. Breathlessness is of course a non-specific symptom and has many causes, particularly in the elderly, and is often confounded by obesity and smoking. It may also be an angina equivalent especially in diabetics. Thus, there has been considerable debate about the reliability of symptoms in this group of patients. Many have suggested that many with the diagnostic label of HFNEF do not have heart failure at all.3 In one study patients being treated for a clinical diagnosis of HFNEF were found to have the same self-reported symptoms and 6-minute walk test (6-MWT) performance as patients with HFREF yet had normal NT-proBNP levels.4 It was concluded that perception of symptoms is disproportionate to the …