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Is heart failure with midrange ejection fraction similar to preserved ejection fraction? Against
La insuficiencia cardiaca con fracción de eyección en rango intermedio ¿es similar a la de fracción de eyección preservada? En contra
F. Formiga
Programa de Geriatría, Servicio de Medicina Interna, IDIBELL, Hospital de Bellvitge, L’Hospitalet de LLobregat, Barcelona, Spain
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En contra" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">LVEF has prognostic importance for patients with HF, which is why the classification of HF in terms of LVEF has been used for years and remains the most widely used method for selecting therapeutic interventions.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> Nevertheless, LVEF might not be the ideal parameter for stratifying patients with heart failure due, among other causes, to the variability associated with its ultrasound estimate, which can lead to classification errors. Given that the LVEF value is actually a continuous variable, it is difficult to establish a specific limit based on which the presence of poor ventricular function can be considered.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Patients with heart failure have historically been classified according to LVEF into 2 categories: HF with reduced EF (HFrEF) and HF with preserved EF (HFpEF). In this context, it has sometimes been erroneously assumed that HFpEF was the same as diastolic HF. Not all patients with HFpEF meet the criteria of diastolic heart failure and, conversely, there can be diastolic abnormalities in patients with HFrEF. An added problem is the lack of consensus on the lower limit of LVEF for classifying heart failure as preserved, a limit that ranges, depending on the author, between 35% and 55%.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In recent years, there have been advances in our understanding of the pathophysiology of HFpEF. It has been clarified that HFpEF is really a collection of pathological conditions (a forest with various trees) that share a clinical condition compatible with HF, a preserved LVEF, an undilated left ventricle and objective evidence of diastolic dysfunction or structural heart disease (left ventricular hypertrophy or increase in atrial size).<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> Given the difficulties entailed in the diagnosis of HFpEF, the measurement of blood concentrations of natriuretic peptides can help confirm or rule out HFpEF.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3–5</span></a> As for the condition's name, it has recently been suggested that rather than using HFpEF we should use HF with normal LVEF, given that LVEF usually decreases with time.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The prevalence of the 2 conditions depends on the study setting, but it is generally accepted that HFpEF represents approximately 40–50% of all cases of HF.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">7,8</span></a> When evaluated in populations controlled by internal medicine or geriatric medicine specialists, the rates usually increase to more than 60%, as in the National Heart Failure Registry (RICA) created by the Heart Failure and Atrial Fibrillation Workgroup of the Spanish Society of Internal Medicine.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> Various clinical characteristics have been described among the 2 classical patient profiles, according to the LVEF. In this respect, patients with HFpEF are more often women, older, have a lower probability of coronary artery disease and have greater associated comorbidity (especially hypertension, diabetes and atrial fibrillation) compared with patients with HFrEF.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However, despite the differences mentioned above, there are few semiological characteristics in acute disease decompensations that allow us to differentiate them.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> In terms of the prognosis, the various comparative studies between HFpEF and HFrEF have at times shown conflicting results, which could be due to, among other factors, the LVEF cutoff chosen for the study. It has been reported that LVEF values smaller than 40% are associated with a progressive increase in mortality.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> Another issue to consider is that the difference in mortality between HFpEF and HFrEF decreases as the patients’ age increases, which is probably due to the increase in deaths of noncardiovascular origin among those who are older. Sudden deaths and death by progressive heart failure seem to be less frequent among patients with HFpEF than among patients with HFrEF.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Given this scenario, the new guidelines for the diagnosis and treatment of heart failure (published last May) incorporate a new category: HF with intermediate LVEF, defined by a LVEF of 40–49% (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Few studies have addressed HF with borderline or intermediate EF (HFiEF), and there are many questions about its rate, clinical characteristics, prognosis and response to treatment.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">12,13</span></a> HFiEF rates have been estimated at 10–20% of all patients with HF.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">14–17</span></a> This low prevalence could be partly due to the fact that many of these patients still have not developed heart failure symptoms.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Although the HFiEF group resembles the HFpEF group in some clinical characteristics, such as a greater proportion of women, advanced age and comorbidity burden,<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> we consider HFiEF a different category from HFpEF. The reason for this opinion is the close association between HFiEF and ischemic heart disease. Almost two thirds of patients with HFiEF have ischemic heart disease, a much higher proportion than in the HFpEF group and similar to that of HFrEF.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Based on this high rate of ischemic heart disease in HFiEF, it can be argued that this is a patient group with HFrEF that is recovering LVEF following base treatment or that the LVEF is deteriorating following an ischemic event.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> Both circumstances support the difference between HFiEF and HFpEF.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Another fact in favor of this hypothesis of 2 different processes are the results of a number of clinical trials that have analyzed these patients with HFiEF. Both in the Candesartan in Heart Failure Reduction in Mortality<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> and the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> substudies, the patients with HFiEF had better results with candesartan and spironolactone, respectively, than those with HFpEF.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The differences are also supported by available morbidity and mortality data. In a study with more than 4000 Medicare patients, the 1-year-adjusted mortality showed no differences between the 3 types of heart failure. However, the number of all-cause readmissions was higher for HFpEF, while the readmissions for cardiovascular reasons were more common among the patients with HFiEF and HFrEF.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> In a study with a 5-year follow-up, Coles et al. observed that patients with HFpEF had lower mortality at 1, 2 and 5 years than patients with HFiEF.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In short, despite the fact that LVEF quantification has various limitations and that in the near future we will probably use other measures to better understand the heart structure and function, it is currently the most widely used tool for classifying heart failure. Given the above, it seems apparent in this context that HFiEF is not similar to HFpEF. Patients with HFiEF should be included as a specific group in future observational studies and clinical trials to better understand their characteristics and, especially, their response to treatments.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflict of interests</span><p id="par0065" class="elsevierStylePara elsevierViewall">The author declares that he has no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:3 [ "identificador" => "xres844953" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec839878" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres844952" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec839877" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interests" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-11-21" "fechaAceptado" => "2017-01-11" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec839878" "palabras" => array:3 [ 0 => "Intermediate heart failure" 1 => "Left ventricular ejection fraction" 2 => "Echocardiogram" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec839877" "palabras" => array:3 [ 0 => "Insuficiencia cardiaca intermedia" 1 => "Fracción de eyección del ventrículo izquierdo" 2 => "Ecocardiograma" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The new European guidelines (2016) for heart failure (HF) include the concept of HF with intermediate left ventricular ejection fraction (LVEF), i.e. an LVEF between 40 and 49%. Although few studies have been carried out, there are claims that HF with intermediate LVEF is not the same as HF with preserved LVEF. Perhaps the most consistent claim is the high percentage of associated ischemic heart disease, which could reflect LVEF recovery after adequate anti-ischemic treatment of HF with depressed LVEF, or even the progressive deterioration of LVEF following an ischemic event.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las nuevas guías europeas 2016 de insuficiencia cardiaca (IC) incorporan el concepto de IC con fracción de eyección del ventrículo izquierdo (FEVI) intermedia, definida por la presencia de una FEVI entre 40 y 49%. Aunque son pocos los estudios que la han evaluado, se dispone de argumentos que apoyarían su existencia como entidad diferenciada de la IC con FEVI preservada. Quizás el más consistente es el alto porcentaje de cardiopatía isquémica asociada, que pudiera reflejar la recuperación de la FEVI tras un adecuado tratamiento antiisquémico de una IC con FEVI deprimida, o bien el deterioro progresivo de la FEVI después de un evento isquémico.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Formiga F. La insuficiencia cardiaca con fracción de eyección en rango intermedio ¿es similar a la de fracción de eyección preservada? En contra. Rev Clin Esp. 2017;217:299–301.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: BNP, B-type natriuretic peptide; LVEF, left ventricular ejection fraction; NT-proBNP, N-terminal pro b-type natriuretic peptide.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Reduced ejection fraction, when LVEF<span class="elsevierStyleHsp" style=""></span><40%.<br>– Intermediate ejection fraction, when LVEF is 40–49%.<br>– Preserved ejection fraction, when LVEF ≥50%.<br><span class="elsevierStyleHsp" style=""></span>All categories require signs and/or symptoms of heart failure for the diagnosis. For patients with intermediate or preserved ejection fraction, the following 2 criteria are also required: increase in natriuretic peptide levels (BNP<span class="elsevierStyleHsp" style=""></span>>35<span class="elsevierStyleHsp" style=""></span>pg/mL and/or NT-proBNP<span class="elsevierStyleHsp" style=""></span>>125<span class="elsevierStyleHsp" style=""></span>pg/mL) and significant cardiac structural impairment (left ventricular hypertrophy and/or left atrial dilation) or diastolic dysfunction data. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1427016.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The 3 diagnostic categories of heart failure according to left ventricular ejection fraction.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "Authors/Task Force Members" "etal" => true "autores" => array:6 [ 0 => "P. 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