Download Heart Failure Whistle Stop Talks

Heart Failure
Whistle Stop Talks
No 1
HFrEF and HFpEF
Definitions for Diagnosis
Susie Bowell BA Hons, RGN
Heart Failure Specialist Nurse
Primary definitions
NICE 2010 Heart Failure (HF) Guidelines (NICE)
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‘Heart failure is a complex clinical syndrome of symptoms and signs that suggest
impairment of the heart as a pump supporting physiological circulation. It is caused by
structural or functional abnormalities of the heart. The demonstration of objective
evidence of these cardiac abnormalities is necessary for the diagnosis of heart failure to
be made’.
European Society of Cardiology HF Guidelines (ESC)2
‘Heart failure can be defined as an abnormality of cardiac structure or function leading to
failure of the heart to deliver oxygen at a rate commensurate with the requirements of
the metabolizing tissues, despite normal filling pressures (or only at the expense of
increased filling pressures)’.
American College of Cardiology Foundation/American Heart Association Task Force
on Practice Guidelines 2013 (ACCF/AHA)3
‘HF is a complex clinical syndrome that results from any structural or functional
impairment of ventricular filling or ejection of blood’.
Clinical manifestations
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1. NICE
‘The
symptoms most commonly encountered are breathlessness (exertional dyspnoea,
0rthopnoea and paroxysmal nocturnal dyspnoea) fatigue and ankle swelling.
Signs in heart failure could be due to pulmonary and systemic congestion, the structural
abnormalities causing heart failure, the structural abnormalities resulting from heart
failure, or from complications of therapy’.
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2. ESC
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......HF is defined, clinically, as a syndrome in which patients have typical symptoms (e.g.
breathlessness, ankle swelling, and fatigue) and signs (e.g. elevated jugular venous
pressure, pulmonary crackles, and displaced apex beat) resulting from an abnormality of
cardiac structure or function.
3.ACCF/AHA
‘The cardinal manifestations of HF are dyspnoea and fatigue, which may limit exercise
tolerance, and fluid retention, which may lead to pulmonary and/or splanchnic congestion
and/or peripheral oedema. Some patients have exercise intolerance but little evidence of
fluid retention, whereas others complain primarily of oedema, dyspnoea, or fatigue.
Because some patients present without signs or symptoms of volume overload, the term
“heart failure” is preferred over “congestive heart failure” ’ .
Diagnostic definitions
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NICE
‘There is no single diagnostic test for heart failure, and diagnosis relies on clinical
judgement based on a combination of history, physical examination and appropriate
investigations’.
ESC
‘Many of the symptoms of HF are non-discriminating and, therefore, of limited diagnostic
value. Many of the signs of HF result from sodium and water retention and resolve quickly
with diuretic therapy, i.e. may be absent in patients receiving such treatment.
Demonstration of an underlying cardiac cause is therefore central to the diagnosis of HF.
For the purposes of these guidelines, HF is defined, clinically, as a syndrome in which
patients have typical symptoms (e.g. breathlessness, ankle swelling, and fatigue) and
signs (e.g. Elevated jugular venous pressure, pulmonary crackles and displaced apex beat)
resulting from an abnormality of cardiac structure or function’.
ACCF/AHA
‘There is no single diagnostic test for HF because it is largely a clinical diagnosis based on
a careful history and physical examination’.
Common predisposing
defining conditions
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NICE
‘The most common cause of heart failure in the UK is coronary artery disease – with many
patients having suffered a myocardial infarction in the past. A history of hypertension is
also common, as is atrial fibrillation. Heart damage of unknown cause – such as dilated
cardiomyopathy – accounts for just under 15% of cases under the age of 75’.
ESC
‘.....usually myocardial disease causing systolic ventricular dysfunction. However,
abnormalities of ventricular diastolic function or of the valves, pericardium, endocardium,
heart rhythm and conduction can also cause HF (and more than one abnormality can be
present)’.
ACCF/AHA
‘The clinical syndrome of HF may result from disorders of the pericardium, myocardium,
endocardium, heart valves, or great vessels or from certain metabolic abnormalities, but
most patients with HF have symptoms due to impaired left ventricular (LV) myocardial
function. HF is not synonymous with either cardiomyopathy or LV dysfunction; these
latter terms describe possible structural or functional reasons for the development of HF’.
spectrum of definitions
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1 NICE
‘Some assert that even in patients with Heart Failure with Preserved Ejection Fraction
(HFpEF) there is an impairment of the contraction of the long axis of the left ventricle.
Others claim that HFpEF is synonymous with diastolic heart failure. The latter is a
controversial term. It does not have a universally accepted definition, it lacks an agreed
detection method(s) and is challenged by those who believe it co-exists with an undetected impairment of systolic function’.
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2 ESC
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‘...more recent, trials enrolled patients with HF and an EF 40–45% and no other causal
cardiac abnormality (such as valvular or pericardial disease). Some of these patients did
not have an entirely normal EF (generally considered to be >50%) but also did not have a
major reduction in systolic function either. Because of this, the term HF with ‘preserved’
EF (HF-PEF) was created to describe these patients’.
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3 ACCF/AHA
‘HF may be associated with a wide spectrum of LV functional abnormalities, which may
range from patients with normal LV size and preserved EF to those with severe dilatation
and/or markedly reduced EF. In most patients, abnormalities of systolic and diastolic
dysfunction co-exist, irrespective of EF’.
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NICE
‘....the two terms LVSD and HFPEF have several limitations. These include the variability of
the left ventricular ejection fraction measured by different imaging modalities, and the
lack of universal agreement on the threshold of ejection fraction at which LVSD and
preserved ejection fraction are defined’.
ESC
‘‘...more recent trials enrolled patients with HF and an EF of 40–45% and no other causal
cardiac abnormality (such as valvular or pericardial disease). Some of these patients did
not have an entirely normal EF (generally considered to be >50%) but also did not have a
major reduction in systolic function either. Because of this, the term HF with ‘preserved’
EF (HFpEF) was created to describe these patients. Patients with an EF in the range 35–
50% therefore represent a ‘grey area’ and most probably have primarily mild systolic
dysfunction’.
ACCF/AHA
‘EF is considered important in classification of patients with HF because of differing
patient demographics, comorbid conditions, prognosis and response to therapies and
because most clinical trials selected patients based on EF. EF values are dependent on the
imaging technique used, method of analysis and operator’.
EF Definitions of hfref and
hfpef by accf/aha
Classification
EF %
Description
Heart Failure with reduced
EF (HFrEF)
≤ 40
Also referred to as systolic HF. Randomised controlled trials
have mainly enrolled patients with HFrEF and it is only these
patients in which efficacious therapies have been
demonstrated to date.
Heart Failure with preserved
EF (HFpEF)
≥ 50
Also referred to as diastolic HF. Several different criteria have
been used to further define HFpEF. The diagnosis of HFpEF is
challenging because it is largely one of excluding other
potential non-cardiac causes of symptoms suggestive of HF.
To date, efficacious therapies have not been identified.
HFpEF borderline
42-49
These patients fall into a borderline or intermediate group.
Their characteristics, treatment patterns and outcomes
appear similar to those of patients with HFpEF
HFpEF improved
> 40
It has been recognised that a subset of patients with HFpEF
previously had HFrEF. These patients with improvement or
recovery in EF may be clinically distinct from those with
persistently preserved or reduced EF. Further research is
needed to better characterise these patients.
Note
The term diastolic dysfunction is not synonymous with HFpEF, however, HFpEF does require
diastolic dysfunction to be present for diagnosis.
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1. NICE Heart Failure Guidelines 2010.
2.European Society of Cardiology Guidelines for the diagnosis and treatment of
acute and chronic heart failure 2012
3. 2013 ACCF/AHA Guideline for the Management of Heart Failure