Tuesday, June 11, 2013

Heart failure with preserved ejection fraction (HFPEF)

---was formerly known as diastolic heart failure. A recent paper was published in the American Journal of Medicine: Contemporary Prevalence and Correlates of Incident Heart Failure with Preserved Ejection Fraction:

We assessed the prevalence of preserved left ventricular ejection fraction in patients with incident heart failure and differences in the demographic and clinical characteristics that may differentiate patients presenting with heart failure with preserved versus reduced left ventricular ejection fraction.
We identified all patients with newly diagnosed heart failure between 2005 and 2008 from 4 sites in the Cardiovascular Research Network on the basis of hospital discharge and ambulatory visit diagnoses, and assigned a category of preserved, borderline, or reduced left ventricular ejection fraction using data from electronic databases and chart review.
We identified 11,994 patients with incident heart failure; of these, 6210 (51.8%) had preserved left ventricular ejection fraction, 1870 (15.6%) had borderline systolic dysfunction, and 3914 (32.6%) had reduced left ventricular ejection fraction.

The authors list these key points:

•Heart failure with preserved left ventricular ejection fraction is the most common form of the heart failure syndrome among patients newly presenting with this condition.
•Women and older adults are especially affected.
•Patients with ejection fractions less than 40% comprise less than one third of those with incident heart failure.
•Evidence-based treatment strategies apply to only a minority of patients with newly diagnosed heart failure.

What does that last statement mean? Treatments have been validated by high level evidence for long term clinical outcomes (for the most part treatments with life prolonging neurohumoral antagonists) only for patients with clearly reduced ejection fractions. But those patients made up less than one third of the incident heart failure cases in this database. There's a commonly held maxim that “there is no evidence-based treatment available for HFPEF.” That's not exactly true. While there's no generalized treatment for the disease per se there are treatments for its manifestations (diuretics for pulmonary edema, rate controlling medications for atrial fibrillation) as well as its associated risk factors and comorbidities. These are, indeed, evidence-based and they treat the patient more than the disease.

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