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The diagnosis of heart failure with preserved ejection fraction (HFpEF) is frequently based on clinical presentation and exclusion of systolic dysfunction. The present study aims to compare the outcome of patients with heart failure with reduced ejection fraction (HFrEF) with those with HFpEF using different diagnostic criteria including echocardiographic evidence for elevated filling pressure.Methods: Of 705 consecutive patients (57.4±16 years, 51% male), cardiac dyspnea (NYHA functional class 2-4) was suspected in 165 patients, in whom the following echocardiographic parameters were assessed: ejection fraction (EF), left atrial size (LA), early and late antegrade mitral flow (E and A), early mitral annular movement (E') and the ratio E/E'. Criteria for HFrEF were typical symptoms (NYHA≥2) and an EF<50%, HFpEF was diagnosed in patients with NYHA ≥2 and EF≥50% using 2 different definitions: the I-Preserve criteria (mainly clinical = HFpEF-I-Preserve) or with additional echocardiographic parameters: E/E'>8 and enlarged LA (HFpEF-Echo). Patients were followed-up for up to 2.5 years (1.7±0.7) and the following events were registered: death, myocardial infarction/coronary intervention, hospitalisation, cardiac transplantation.Results: HFrEF was diagnosed in 51 (30.9%) and HFpEF-Echo in 57 (33,9%) patients. 114 (69.1%) patients fulfilled the I-Preserve criteria for HFpEF. Patients with HFpEF were significantly older, more often female and obese. Kaplan-Meier-analysis revealed a significantly higher event rate in patients with HFrEF than in the HFpEF-Echo and HFpEF-I-Preserve group (62.7% vs. 28.6% vs. 24.6%, p<0.001, log rank).Conclusion: Patients with HFrEF have a worse prognosis than those with HFpEF, irrespective of echocardiographic or clinical definition of HFpEF.