Heart failure with preserved ejection fraction (HFpEF; “Hefpef” so to say.)
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At first, I intended to make 4 papers on heart failure, but I have to do 2 parts more to complete my review of heart failure. The second extra one will be about rehabilitation and lifestyle. The subject of this one is heart failure with preserved ejection fraction (HFpEF or “hef-pef”).
The ejection fraction (EF) is the amount of blood the heart throws out to the aorta with each heart beat. It is expressed as a percentage of the total volume that was in the heart before it contracted. For example, if the volume of blood in the heart is 100cc before contraction and 40cc after contraction then the heart pumped out 60cc, so the ejection fraction is 60%.
Heart failure patients have an EF below 40%, period. What period? No period at all!
You see it turns out that half of all heart failure patients actually have an EF that is more than the 40% cut-off value, and in a third of all cases the EF is even above 50%, a value that is usually considered to be normal.
So we have two groups of patients: those with low or borderline EF (about two-thirds of all heart failure patients) and another group with normal or ‘preserved’ EF. The first group with reduced ejection fraction are known as ‘HFrEF’ (“hef-ref”) and the second group with preserved ejection fraction are known as ‘HFpEF’ (“hef-pef”). It is the second group of patients that are the focus of this article.
Our knowledge about “hef-pef” has increased tremendously in the last 15 years. Alas, the treatment options haven’t grown as much.
20 years ago, “hef-pef” was known as ‘diastolic heart failure’. Diastole is the relaxation phase of the heart cycle. Using echocardiography (ultrasound) we see that in these patients the heart cannot relax properly between contractions because the muscle fibres are thicker, shorter and do not stretch as easily as they should.
The result of having a stiffer heart is that it doesn’t get filled with enough blood before the next contraction begins. Starting with a low volume inside the heart means that, even though a good proportion may be pumped out each time, the actual amount of blood pumped out may still fail to meet the body’s requirements and so the patient has ‘heart failure’.
“Hef-pef” patients have a lot of co-morbidities (extra diseases such as: being overweight; hypertension; diabetes; metabolic syndrome). How do we know that “hef-pef” is an identity and not just a situation of having a few or more co-morbidities? A single blood test can tell the difference.
The patients with “hef-pef” have an elevated value of a test called NT pro-BNP. This test reflects heart muscle damage and people with elevated levels have to be hospitalized far more than people who have the same co-morbidities but with a normal NT pro-BNP.
We’ve been able to find at least 3 different groups at risk for developing “hef-pef”. These are:
1) obese elderly western women with hypertension,
2) obese young men, especially those with too much belly fat,
3) skinny Asian women with type-2 diabetes (our doctors must be especially mindful of this group).
Symptoms can be hard to pick up because of all the co-morbidities and patients can easily be mis-diagnosed as having complications of other disorders when in fact it is heart failure that they have as well.
There is one symptom in particular that is very important: exercise-induced shortness of breath. This has to be differentiated from exercise-induced asthma. An echocardiogram and the lab test can make this differentiation.
How to diagnose “hef-pef”.
Doctors in the USA and those in Europe use different sets of rules to diagnose “hef-pef”. Each is based on a scoring system that adds points according to whether or not a patient has a certain symptom or sign. Because the two systems differ, it’s possible to have “hef-pef” on one side of the Atlantic and not on the other!
How to treat “hef-pef”.
There is no specific treatment yet for “hef-pef” and for now the treatment focuses on reducing volume overload (by using diuretics) and treating the co-morbidities. A lot of studies are ongoing everywhere in the world with all the newer heart failure medications. The results will be available in the next 3 to 5 years.
I strongly recommend that you read, comment and share because any one of us can develop heart failure. To prevent is way better than to (maybe) cure, so we recommend a physical check every year. Call Be Well Medical Center to ask for a yearly medical check, especially on cardiovascular diseases.
Ben van Zoelen, retired cardiologist from the Netherlands and member of the Advisory Board of Be Well Medical Center, Hua Hin.