**2.1 Characteristics of medical examination**

Patients with DHF were shown to have similar pathophysiological characteristics, compared with HF patients with a reduced EF including reduced exercise capacity and impaired quality of life. The Framingham criteria for diagnosis of HF is the following. Major criteria are 1) paroxysmal nocturnal dyspnea or orthopnea, 2) jugular venous distention (or central venous pressure is more than 16 mmHg), 3) hearing rale or acute pulmonary edema, 4) cardiomegaly, 5) hepatojuglar reflex, and 6) response to diuretics (weight loss is more than 4.5 kg per 5 days). Minor criteria are 1) ankle edema, 2) nocturnal cough, 3) exertional dyspnea, 4) pleural effusion, 5) vital capacity lower less than two thirds of normal condition, 6) hepatomegaly, and 7) tachycardia (more than 120 beats/minute. With diastolic HF, fourth heart sounds may be present but third heart sounds are seldom present. Chest radiography will show pulmonary congestion during acute exacerbations and for some time following an episode, cardiomegaly will be present in systolic HF but may or may not be present in HF with preserved ejection fraction. When it is difficult with diagnosing HF, it is important to use echocardiography. [9,10]
