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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">LVEF has prognostic importance for patients with HF&#44; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> Nevertheless&#44; LVEF might not be the ideal parameter for stratifying patients with heart failure due&#44; among other causes&#44; to the variability associated with its ultrasound estimate&#44; which can lead to classification errors&#46; Given that the LVEF value is actually a continuous variable&#44; it is difficult to establish a specific limit based on which the presence of poor ventricular function can be considered&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Patients with heart failure have historically been classified according to LVEF into 2 categories&#58; HF with reduced EF &#40;HFrEF&#41; and HF with preserved EF &#40;HFpEF&#41;&#46; In this context&#44; it has sometimes been erroneously assumed that HFpEF was the same as diastolic HF&#46; Not all patients with HFpEF meet the criteria of diastolic heart failure and&#44; conversely&#44; there can be diastolic abnormalities in patients with HFrEF&#46; An added problem is the lack of consensus on the lower limit of LVEF for classifying heart failure as preserved&#44; a limit that ranges&#44; depending on the author&#44; between 35&#37; and 55&#37;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In recent years&#44; there have been advances in our understanding of the pathophysiology of HFpEF&#46; It has been clarified that HFpEF is really a collection of pathological conditions &#40;a forest with various trees&#41; that share a clinical condition compatible with HF&#44; a preserved LVEF&#44; an undilated left ventricle and objective evidence of diastolic dysfunction or structural heart disease &#40;left ventricular hypertrophy or increase in atrial size&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> Given the difficulties entailed in the diagnosis of HFpEF&#44; the measurement of blood concentrations of natriuretic peptides can help confirm or rule out HFpEF&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#8211;5</span></a> As for the condition&#39;s name&#44; it has recently been suggested that rather than using HFpEF we should use HF with normal LVEF&#44; given that LVEF usually decreases with time&#46;<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&#44; but it is generally accepted that HFpEF represents approximately 40&#8211;50&#37; of all cases of HF&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">7&#44;8</span></a> When evaluated in populations controlled by internal medicine or geriatric medicine specialists&#44; the rates usually increase to more than 60&#37;&#44; as in the National Heart Failure Registry &#40;RICA&#41; created by the Heart Failure and Atrial Fibrillation Workgroup of the Spanish Society of Internal Medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> Various clinical characteristics have been described among the 2 classical patient profiles&#44; according to the LVEF&#46; In this respect&#44; patients with HFpEF are more often women&#44; older&#44; have a lower probability of coronary artery disease and have greater associated comorbidity &#40;especially hypertension&#44; diabetes and atrial fibrillation&#41; compared with patients with HFrEF&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; despite the differences mentioned above&#44; there are few semiological characteristics in acute disease decompensations that allow us to differentiate them&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> In terms of the prognosis&#44; the various comparative studies between HFpEF and HFrEF have at times shown conflicting results&#44; which could be due to&#44; among other factors&#44; the LVEF cutoff chosen for the study&#46; It has been reported that LVEF values smaller than 40&#37; are associated with a progressive increase in mortality&#46;<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&#8217; age increases&#44; which is probably due to the increase in deaths of noncardiovascular origin among those who are older&#46; Sudden deaths and death by progressive heart failure seem to be less frequent among patients with HFpEF than among patients with HFrEF&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Given this scenario&#44; the new guidelines for the diagnosis and treatment of heart failure &#40;published last May&#41; incorporate a new category&#58; HF with intermediate LVEF&#44; defined by a LVEF of 40&#8211;49&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<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 &#40;HFiEF&#41;&#44; and there are many questions about its rate&#44; clinical characteristics&#44; prognosis and response to treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">12&#44;13</span></a> HFiEF rates have been estimated at 10&#8211;20&#37; of all patients with HF&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">14&#8211;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&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Although the HFiEF group resembles the HFpEF group in some clinical characteristics&#44; such as a greater proportion of women&#44; advanced age and comorbidity burden&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> we consider HFiEF a different category from HFpEF&#46; The reason for this opinion is the close association between HFiEF and ischemic heart disease&#46; Almost two thirds of patients with HFiEF have ischemic heart disease&#44; a much higher proportion than in the HFpEF group and similar to that of HFrEF&#46;<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&#44; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> Both circumstances support the difference between HFiEF and HFpEF&#46;</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&#46; 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&#44; the patients with HFiEF had better results with candesartan and spironolactone&#44; respectively&#44; than those with HFpEF&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The differences are also supported by available morbidity and mortality data&#46; In a study with more than 4000 Medicare patients&#44; the 1-year-adjusted mortality showed no differences between the 3 types of heart failure&#46; However&#44; the number of all-cause readmissions was higher for HFpEF&#44; while the readmissions for cardiovascular reasons were more common among the patients with HFiEF and HFrEF&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> In a study with a 5-year follow-up&#44; 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PROS AND CONS
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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