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) 1 ‘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 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’. 2. ESC ‘......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 1. 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’. 2. 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’. 3. 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’.

1 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’. 2 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)’. 3 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’. Common predisposing defining conditions

spectrum of definitions 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 un- detected impairment of systolic function’. 2 ESC ‘...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’. 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 ’.

1 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’. 2 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’. 3 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 hf r ef and hf p ef by accf/aha Note The term diastolic dysfunction is not synonymous with HFpEF, however, HFpEF does require diastolic dysfunction to be present for diagnosis.

1. NICE Heart Failure Guidelines European Society of Cardiology Guidelines for the diagnosis and treatment of acute and chronic heart failure ACCF/AHA Guideline for the Management of Heart Failure