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Desai N, Olewinska E, Famulska A, Remuzat C, Francois C, Folkerts K. Heart failure with mildly reduced and preserved ejection fraction: A review of disease burden and remaining unmet medical needs within a new treatment landscape. Heart Fail Rev 2024; 29:631-662. [PMID: 38411769 PMCID: PMC11035416 DOI: 10.1007/s10741-024-10385-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2024] [Indexed: 02/28/2024]
Abstract
This review provides a comprehensive overview of heart failure with mildly reduced and preserved ejection fraction (HFmrEF/HFpEF), including its definition, diagnosis, and epidemiology; clinical, humanistic, and economic burdens; current pharmacologic landscape in key pharmaceutical markets; and unmet needs to identify key knowledge gaps. We conducted a targeted literature review in electronic databases and prioritized articles with valuable insights into HFmrEF/HFpEF. Overall, 27 randomized controlled trials (RCTs), 66 real-world evidence studies, 18 clinical practice guidelines, and 25 additional publications were included. Although recent heart failure (HF) guidelines set left ventricular ejection fraction thresholds to differentiate categories, characterization and diagnosis criteria vary because of the incomplete disease understanding. Recent epidemiological data are limited and diverse. Approximately 50% of symptomatic HF patients have HFpEF, more common than HFmrEF. Prevalence varies with country because of differing definitions and study characteristics, making prevalence interpretation challenging. HFmrEF/HFpEF has considerable mortality risk, and the mortality rate varies with study and patient characteristics and treatments. HFmrEF/HFpEF is associated with considerable morbidity, poor patient outcomes, and common comorbidities. Patients require frequent hospitalizations; therefore, early intervention is crucial to prevent disease burden. Recent RCTs show promising results like risk reduction of composite cardiovascular death or HF hospitalization. Costs data are scarce, but the economic burden is increasing. Despite new drugs, unmet medical needs requiring new treatments remain. Thus, HFmrEF/HFpEF is a growing global healthcare concern. With improving yet incomplete understanding of this disease and its promising treatments, further research is required for better patient outcomes.
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Affiliation(s)
- Nihar Desai
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
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Thompson L, Carr F, Rogers D, Lewis N, Charalampopoulos A, Fent G, Garg P, Swift AJ, Al-Mohammad A. Characterisation of the octogenarians presenting to the diagnostic heart failure clinic: SHEAF registry. Open Heart 2024; 11:e002584. [PMID: 38663890 PMCID: PMC11043696 DOI: 10.1136/openhrt-2023-002584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
INTRODUCTION Heart failure (HF) incidence is increasing in older adults with high hospitalisation and mortality rates. Treatment is complicated by side effects and comorbidities. We investigated the clinical characteristics of octogenarians presenting to the HF clinic. METHODS Data were collected on octogenarians (80-89 years) referred to the HF clinic in two periods. The data included demographics, HF phenotype, comorbidities, symptoms and treatment. We investigate the temporal changes in clinical characteristics using χ2 test. We aimed to determine the clinical characteristics which were associated with optimisation of HF pharmacological intervention in the clinic, conducting multivariate regression analysis. Statistical significance is determined at p<0.05. RESULTS Data were collected in April 2012 to January 2014 and in June 2021 to December 2022. In this cross-sectional study of temporal data, 571 octogenarians were referred to the clinic in the latter period, in whom the prevalence of HF was 68.48% (391 patients). HF with preserved ejection fraction (HFpEF) was the most common phenotype and increased significantly compared with the first period (46.3% and 29.2%, p<0.001). Frailty, chronic kidney disease and ischaemic heart disease increased significantly versus the first period (p<0.001). During the second period, and following the consultation, of the patients with HF with reduced ejection fraction (HFrEF), 86.4% and 82.7% were on a beta blocker and on an ACE inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, respectively. Clinical characteristics associated with further optimisations of HF pharmacological therapy in the HF clinic were: New York Heart Association (NYHA) functional class III and the presence of HFrEF phenotype CONCLUSIONS: With a prevalence of HF at 68% among the octogenarians referred to the HF clinic, HFpEF incidence is rising. The decision to optimise HF pharmacological treatment in octogenarians is driven by NYHA functional class III and the presence of HFrEF phenotype.
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Affiliation(s)
- Luke Thompson
- Care of the Elderly, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Fiona Carr
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Geriatrics, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Dominic Rogers
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nigel Lewis
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Graham Fent
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Pankaj Garg
- University of East Anglia, Norwich, Norfolk, UK
| | - Andrew J Swift
- Division of Clinical Medicine, The University of Sheffield Faculty of Medicine Dentistry and Health, Sheffield, UK
| | - Abdallah Al-Mohammad
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, The University of Sheffield Faculty of Medicine Dentistry and Health, Sheffield, UK
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Morton G, Moore J. Systems of care for heart failure: bridging the divide between primary care and specialist services. Heart 2023; 109:1564-1570. [PMID: 37147130 DOI: 10.1136/heartjnl-2022-321757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Affiliation(s)
- Geraint Morton
- Cardiology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Jim Moore
- Gloucestershire Heart Failure Service, Gloucestershire Health and Care NHS Foundation Trust, Gloucester, UK
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Zhang S, Liu C, Zhang Y, Wu Z, Feng K, Lai Y, Pei J, Guan T. Different heart failure phenotypes of valvular heart disease: the role of mitochondrial dysfunction. Front Cardiovasc Med 2023; 10:1135938. [PMID: 37273869 PMCID: PMC10235483 DOI: 10.3389/fcvm.2023.1135938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 04/28/2023] [Indexed: 06/06/2023] Open
Abstract
Valvular heart disease (VHD)-related heart failure (HF) is a special subtype of HF with an increasingly concerned heterogeneity in pathophysiology, clinical phenotypes, and outcomes. The mechanism of VHD-related HF involves not only mechanical damage to the valve itself but also valve lesions caused by myocardial ischemia. The interactions between them will lead to the occurrence and development of VHD-related HF subtypes. Due to the spatial (combination of different valvular lesions) and temporal effects (sequence of valvular lesions) of valvular damages, it can make the patient's condition more complicated and also make the physicians deal with a dilemma when deciding on a treatment plan. This indicates that there is still lack of deep understanding on the pathogenic mechanism of VHD-related HF subtypes. On the other hand, mitochondrial dysfunction (MitD) is not only associated with the development of numerous cardiac diseases such as atherosclerosis, hypertension, diabetes, and HF but also occurs in VHD. However, the role of MitD in VHD-related HF is still not fully recognized. In this comprehensive review, we aim to discuss the current findings and challenges of different valvular damages derived from HF subtypes as well as the role of MitD in VHD-related HF subtypes.
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Affiliation(s)
- Shenghui Zhang
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, China
- Department of Cardiology, Guangzhou First People’s Hospital, South China University of Technology, Guangzhou, China
| | - Cheng Liu
- Department of Cardiology, Guangzhou First People’s Hospital, South China University of Technology, Guangzhou, China
- Department of Cardiology, Guangzhou First People’s Hospital, Guangzhou Medical University, Guangzhou, China
| | - Yingyuan Zhang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zongjian Wu
- City School, Guangzhou Academy of Fine Arts, Guangzhou, China
| | - Kaiwei Feng
- Department of Cardiology, Guangzhou First People’s Hospital, Guangzhou Medical University, Guangzhou, China
| | - Yanxian Lai
- Department of Cardiology, Guangzhou First People’s Hospital, South China University of Technology, Guangzhou, China
- Department of Cardiology, Guangzhou First People’s Hospital, Guangzhou Medical University, Guangzhou, China
| | - Jingxian Pei
- Department of Cardiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Tianwang Guan
- Department of Cardiology, Guangzhou First People’s Hospital, Guangzhou Medical University, Guangzhou, China
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Obokata M, Sorimachi H, Harada T, Kagami K, Saito Y, Ishii H. Epidemiology, Pathophysiology, Diagnosis, and Therapy of Heart Failure With Preserved Ejection Fraction in Japan. J Card Fail 2023; 29:375-388. [PMID: 37162126 DOI: 10.1016/j.cardfail.2022.09.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 03/17/2023]
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) is a global health care problem, with diagnostic difficulty, limited treatment options and high morbidity and mortality rates. The prevalence of HFpEF is increasing because of the aging population and the increasing burden of cardiac and metabolic comorbidities, such as systemic hypertension, diabetes, chronic kidney disease, and obesity. The knowledge base is derived primarily from the United States and Europe, and data from Asian countries, including Japan, remain limited. Given that phenotypic differences may exist between Japanese and Western patients with HFpEF, careful characterization may hold promise to deliver new therapy specific to the Japanese population. In this review, we summarize the current knowledge regarding the epidemiology, pathophysiology and diagnosis of and the potential therapies for HFpEF in Japan.
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Affiliation(s)
- Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tomonari Harada
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Kazuki Kagami
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan; Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yuki Saito
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan; Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Aoki S, Yamagishi K, Kihara T, Tanaka M, Imano H, Muraki I, Shimizu Y, Hayama‐Terada M, Umesawa M, Sankai T, Okada T, Kitamura A, Kiyama M, Iso H. Risk factors for pre-heart failure or symptomatic heart failure based on NT-proBNP. ESC Heart Fail 2022; 10:90-99. [PMID: 36151844 PMCID: PMC9871651 DOI: 10.1002/ehf2.14149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 08/09/2022] [Accepted: 09/05/2022] [Indexed: 01/27/2023] Open
Abstract
AIMS Evidence on the risk factors for incident heart failure in Asia has been limited. We sought to identify the risk factors for pre-heart failure or symptomatic heart failure, based on N-terminal pro-B-type natriuretic peptide (NT-proBNP), in the Japanese general population. METHODS We performed a retrospective cohort study based on the Circulatory Risk in Communities Study involving 5335 Japanese individuals whose NT-proBNP levels were measured between 2010 and 2015. Of these, 2768 people aged between 30 and 69 years who undertook annual cardiovascular risk surveys at least once between 1990 and 2000 were retrospectively eligible to be participants in this study. We performed multivariable logistic regression analyses to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) of pre-heart failure or symptomatic heart failure defined as NT-proBNP >400 pg/mL or as having a diagnosis of heart failure and taking medication for heart failure for several cardiovascular risk factors (body mass index, blood pressure, diabetes mellitus, total cholesterol, triglyceride, smoking status, drinking status). RESULTS We identified 85 cases of heart failure. The multivariable ORs (95% CIs) were 5.70 (2.70-12.0) for body mass index of 27-29.9 kg/m2 and 5.91 (2.19-16.0) for ≥30 kg/m2 compared with 21-22.9 kg/m2 ; 2.49(1.01-6.13) for systolic blood pressure of ≥160 mmHg vs. <130 mmHg; 2.87(1.23-6.68) for diastolic blood pressure of ≥100 mmHg vs. <80 mmHg; 5.16(2.14-12.4) for diabetes vs. non-diabetes; and 2.24 (0.92-5.49) for current smokers of ≥20 cigarettes/day vs. never smokers. The multivariable ORs (95% CIs) of the number of risk factors, defined as the sum of four risk factors (obesity, hypertension, diabetes, and current smoker) was 6.80 (3.69-12.5) for ≥2 risk factors vs. no risk factors. CONCLUSIONS The accumulation of these risk factors was associated with a graded higher risk of pre-heart failure or symptomatic heart failure.
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Affiliation(s)
- Shoko Aoki
- Department of Public Health Medicine, Faculty of Medicine, and Health Services Research and Development CenterUniversity of TsukubaTsukubaJapan
| | - Kazumasa Yamagishi
- Department of Public Health Medicine, Faculty of Medicine, and Health Services Research and Development CenterUniversity of TsukubaTsukubaJapan,Osaka Center for Cancer and Cardiovascular Disease PreventionOsakaJapan,Ibaraki Western Medical CenterChikuseiJapan
| | - Tomomi Kihara
- Department of Public Health Medicine, Faculty of Medicine, and Health Services Research and Development CenterUniversity of TsukubaTsukubaJapan
| | - Mari Tanaka
- Public Health, Department of Social MedicineOsaka University Graduate School of MedicineSuitaJapan,Department of Public HealthKindai UniversityOsakasayamaJapan
| | - Hironori Imano
- Osaka Center for Cancer and Cardiovascular Disease PreventionOsakaJapan,Public Health, Department of Social MedicineOsaka University Graduate School of MedicineSuitaJapan,Department of Public HealthKindai UniversityOsakasayamaJapan
| | - Isao Muraki
- Public Health, Department of Social MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Yuji Shimizu
- Osaka Center for Cancer and Cardiovascular Disease PreventionOsakaJapan
| | - Mina Hayama‐Terada
- Osaka Center for Cancer and Cardiovascular Disease PreventionOsakaJapan,Yao City Public Health CenterYaoJapan
| | - Mitsumasa Umesawa
- Department of Public Health Medicine, Faculty of Medicine, and Health Services Research and Development CenterUniversity of TsukubaTsukubaJapan,School of MedicineDokkyo Medical UniversityMibuJapan
| | - Tomoko Sankai
- Department of Public Health and Nursing, Faculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Takeo Okada
- Osaka Center for Cancer and Cardiovascular Disease PreventionOsakaJapan
| | - Akihiko Kitamura
- Osaka Center for Cancer and Cardiovascular Disease PreventionOsakaJapan,Yao City Public Health CenterYaoJapan
| | - Masahiko Kiyama
- Osaka Center for Cancer and Cardiovascular Disease PreventionOsakaJapan
| | - Hiroyasu Iso
- Department of Public Health Medicine, Faculty of Medicine, and Health Services Research and Development CenterUniversity of TsukubaTsukubaJapan,Public Health, Department of Social MedicineOsaka University Graduate School of MedicineSuitaJapan,Institute for Global Health Policy Research Center, Bureau of International Health CooperationNational Center for Global Health and MedicineTokyoJapan
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7
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Garg P, Swift AJ. Importance of cardiac magnetic resonance imaging assessment of left ventricular filling pressure at resting state. Eur Heart J 2022; 43:3495. [PMID: 35929602 DOI: 10.1093/eurheartj/ehac420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Pankaj Garg
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK.,Cardiovascular and Metabolic Health, Norwich Medical School, University of East Anglia, Norwich, UK.,Cardiology Department, Norfolk and Norwich University Teaching Hospitals, Norwich, UK
| | - Andrew J Swift
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
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8
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Wolodimeroff E, Garg P, Swift AJ, Fent G, Lewis N, Rogers D, Charalampopoulos A, Al-Mohammad A. Cardiovascular medication in patients with raised NT-proBNP, but no heart failure in the SHEAF registry. Open Heart 2022; 9:e001974. [PMID: 35649572 PMCID: PMC9161074 DOI: 10.1136/openhrt-2022-001974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/18/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES We aim to assess the association of cardiovascular medications with outcomes of patients referred to the diagnostic heart failure (HF) clinic with symptoms or signs of possible HF, raised N-terminal pro-brain-type natriuretic peptide (NT-proBNP) but no evidence of HF on transthoracic echocardiography (TTE). METHODS Data were collected prospectively into the Sheffield HEArt Failure (SHEAF) registry between April 2012 and January 2020. The inclusion criteria were symptoms or signs suggestive of HF, NT-proBNP >400 pg/mL, but no evidence of HF on TTE. Cox proportional-hazards regression model was used to investigate the association between the survival time of patients and different cardiovascular medications. The outcome was defined as all-cause mortality. RESULTS From the SHEAF registry, we identified 1766 patients with raised NT-proBNP with no evidence of HF on TTE. Survival was higher among the younger patients, and among those with hypertension or atrial fibrillation (AF). Mortality was increased with male gender, valvular heart disease and chronic kidney disease. Using univariate Cox proportional-hazards regression, the only cardiac therapeutic agent independently associated with all-cause mortality was beta-blocker (HR 0.86; 95% CI: 0.77 to 0.97; p=0.02). The use of beta-blockers was significantly higher in patients with AF (63% vs 39%, p<0.01) and hypertension (51% vs 42%, p<0.01). However, using multivariate Cox proportional-hazards regression to adjust for all variables associated with mortality, the influence of beta-blockers became non-significant (HR 0.96; 95% CI: 0.85 to 1.1, p=0.49). CONCLUSION When all variables associated with mortality are considered, none of the cardiovascular agents are associated with the improved survival of patients with suspected HF, raised NT-proBNP but no HF on echocardiography.
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Affiliation(s)
- Elena Wolodimeroff
- Department of Infection, Immunity & Cardiovascular Disease, The University of Sheffield Medical School, Sheffield, UK
| | - Pankaj Garg
- Department of Infection, Immunity & Cardiovascular Disease, The University of Sheffield Medical School, Sheffield, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Andrew J Swift
- Department of Infection, Immunity & Cardiovascular Disease, The University of Sheffield Medical School, Sheffield, UK
| | - Graham Fent
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nigel Lewis
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Dominic Rogers
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Abdallah Al-Mohammad
- Department of Infection, Immunity & Cardiovascular Disease, The University of Sheffield Medical School, Sheffield, UK
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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9
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Morton G, Bolam H, Hirmiz Z, Chahal R, Guha K, Kalra PR. NICE diagnostic heart failure pathway: screening referrals identifies patients better served by community-based management. ESC Heart Fail 2021; 8:5600-5605. [PMID: 34569187 PMCID: PMC8712913 DOI: 10.1002/ehf2.13608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 08/16/2021] [Accepted: 09/01/2021] [Indexed: 11/10/2022] Open
Abstract
AIMS Evaluate whether UK National Institute for Health & Care Excellence (NICE) chronic heart failure (HF) guidelines can be safely and effectively refined through specialist referral management. METHODS AND RESULTS All referrals to a UK centre 1/3/2019-30/5/2019 and 1/6/2020-31/7/2020 were reviewed by HF specialists. Patients were triaged to specialist assessment in HF clinic, according to the NICE HF diagnostic pathway [urgency based on N-terminal pro brain natriuretic peptide (NTproBNP) levels], or the referrer given remote Advice & Guidance (A&G), to aid primary care management. Standardized triage criteria for recommending primary care management were (i) presentation inconsistent with HF, (ii) competing comorbidity/frailty meant specialist assessment in clinic not in patient's best interests, (iii) recent assessment for same condition, or (iv) patient had known HF. Following triage patients managed in the primary care were categorized as low or high risk of adverse outcomes. Outcome measures were 90 day all-cause and HF hospital admission and mortality rates. Four hundred and eighty-six patients had the median age of 80 (74-86) years, and 253 (52%) were male. Two hundred and six (42%) had NTproBNP > 2000 pg/mL. Primary care management was recommended for 128 patients (26%): 105 (22%) A&G alone and 23 input from community HF nurse specialists. Primary care management was recommended due to the following: presentation inconsistent with HF 53 (42%), more important competing comorbidity/frailty 35 (27%), recent assessment 17 (13%), and known HF 23 (18%). Patients managed in primary care had higher rates of all-cause hospitalization (30% vs. 19%; P = 0.018) and death (7% vs. 2%; P = 0.0054) than those seen in HF clinic. Of those managed in primary care, 50 (39%) were determined to be at low risk and 78 (61%) at high risk. High-risk patients were older (87 vs. 80 years; P = 0.0026), had much higher NTproBNP (2666 vs. 697 pg/mL; P < 0.0001), and were managed in the primary care due to severe comorbidity (45%) or known HF (31%). They had extremely high rates of adverse outcomes: 35 all-cause hospitalization (45%), 12 HF hospitalization (15%), and 9 deaths (12%). Low-risk patients were usually felt not to have HF (86%) and confirmed to have low rates of adverse outcomes: three all-cause hospitalizations (6%; P < 0.0001 compared with high risk) and zero HF hospitalization (P = 0.0033) or death (P = <0.012). CONCLUSIONS Incorporating specialist referral management into NICE HF diagnostic pathway reduces the demand on HF clinics and may improve the patient experience by facilitating community care. However, many of the patients identified for primary care management are at very high risk of adverse outcomes in the short term and are frequently hospitalized. Urgent implementation of alternative pathways and community-based care packages in parallel for these high-risk patients is extremely important.
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Affiliation(s)
- Geraint Morton
- Department of CardiologyQueen Alexandra Hospital, Portsmouth Hospitals University NHS TrustPortsmouthUK
| | - Helena Bolam
- Department of CardiologyQueen Alexandra Hospital, Portsmouth Hospitals University NHS TrustPortsmouthUK
| | - Zaid Hirmiz
- Hampshire, Southampton and Isle of Wight CCGHampshireUK
| | - Raj Chahal
- Department of CardiologyUniversity Hospitals Dorset NHS Foundation TrustPooleUK
| | - Kaushik Guha
- Department of CardiologyQueen Alexandra Hospital, Portsmouth Hospitals University NHS TrustPortsmouthUK
| | - Paul R. Kalra
- Department of CardiologyQueen Alexandra Hospital, Portsmouth Hospitals University NHS TrustPortsmouthUK
- Faculty of Science and HealthUniversity of PortsmouthPortsmouthUK
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Forsyth F, Brimicombe J, Cheriyan J, Edwards D, Hobbs FR, Jalaludeen N, Mant J, Pilling M, Schiff R, Taylor CJ, Zaman MJ, Deaton C, Chakravorty M, Maclachlan S, Kane E, Odone J, Thorley N, Borja‐Boluda S, Wellwood I, Sowden E, Blakeman T, Chew‐Graham C, Hossain M, Sharpley J, Gordon B, Taffe J, Long A, Aziz A, Swayze H, Rutter H, Schramm C, MacDonald S, Papworth H, Smith J, Needs C, Cronk D, Newark C, Blake D, Brown A, Basuita A, Gayton E, Glover V, Fox R, Crawshaw J, Ashdown H, A'Court C, Ayerst R, Hernandez‐Diaz B, Knox K, Wooding N, Wanninayake S, Keast C, Jones A, Brown K, Gaw M, Thomas N, Dixon S, Angeleri‐Rand E. Diagnosis of patients with heart failure with preserved ejection fraction in primary care: cohort study. ESC Heart Fail 2021. [PMCID: PMC8712851 DOI: 10.1002/ehf2.13612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Aims Heart failure with preserved ejection fraction (HFpEF) accounts for half of all heart failure (HF), but low awareness and diagnostic challenges hinder identification in primary care. Our aims were to evaluate the recruitment and diagnostic strategy in the Optimise HFpEF cohort and compare with recent recommendations for diagnosing HFpEF. Methods and results Patients were recruited from 30 primary care practices in two regions in England using an electronic screening algorithm and two secondary care sites. Baseline assessment collected clinical and patient‐reported data and diagnosis by history, assessment, and trans‐thoracic echocardiogram (TTE). A retrospective evaluation compared study diagnosis with H2FPEF score and HFA‐PEFF diagnostic algorithm. A total of 152 patients (86% primary care, mean age 78.5, 40% female) were enrolled; 93 (61%) had HFpEF confirmed. Most participants had clinical features of HFpEF, but those with confirmed HFpEF were more likely female, obese, functionally impaired, and symptomatic. Some echocardiographic findings were diagnostic for HFpEF, but no difference in natriuretic peptide levels were observed. The H2FPEF and HFA‐PEFF scores were not significantly different by group, although confirmed HFpEF cases were more likely to have scores indicating high probability of HFpEF. Conclusions Patients with HFpEF in primary care are difficult to identify, and greater awareness of the condition, with clear diagnostic pathways and specialist support, are needed. Use of diagnostic algorithms and scores can provide systematic approaches to diagnosis but may be challenging to apply in older multi‐morbid patients. Where diagnostic uncertainty remains, pragmatic decisions are needed regarding the value of additional testing versus management of presumptive HFpEF.
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Affiliation(s)
- Faye Forsyth
- Primary Care Unit, Department of Public Health and Primary Care University of Cambridge School of Clinical Medicine East Forvie, Cambridge Biomedical Campus Cambridge CB2 0SR UK
| | - James Brimicombe
- Primary Care Unit, Department of Public Health and Primary Care University of Cambridge School of Clinical Medicine East Forvie, Cambridge Biomedical Campus Cambridge CB2 0SR UK
| | - Joseph Cheriyan
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine University of Cambridge School of Clinical Medicine Cambridge UK
| | - Duncan Edwards
- Primary Care Unit, Department of Public Health and Primary Care University of Cambridge School of Clinical Medicine East Forvie, Cambridge Biomedical Campus Cambridge CB2 0SR UK
| | - F.D. Richard Hobbs
- Nuffield Department of Primary Care Health Sciences University of Oxford Oxford UK
| | - Navazh Jalaludeen
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine University of Cambridge School of Clinical Medicine Cambridge UK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care University of Cambridge School of Clinical Medicine East Forvie, Cambridge Biomedical Campus Cambridge CB2 0SR UK
| | - Mark Pilling
- Primary Care Unit, Department of Public Health and Primary Care University of Cambridge School of Clinical Medicine East Forvie, Cambridge Biomedical Campus Cambridge CB2 0SR UK
| | - Rebekah Schiff
- Department of Ageing and Health Guy's and St. Thomas' NHS Foundation Trust London UK
| | - Clare J. Taylor
- Nuffield Department of Primary Care Health Sciences University of Oxford Oxford UK
| | - M. Justin Zaman
- Department of Cardiology West Suffolk Hospital Bury St Edmonds UK
| | - Christi Deaton
- Primary Care Unit, Department of Public Health and Primary Care University of Cambridge School of Clinical Medicine East Forvie, Cambridge Biomedical Campus Cambridge CB2 0SR UK
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