Clinical features and echo profile in suspected heart Failure with preserved ejection fraction
INTRODUCTION
Heart failure is a growing epidemic condition and nearly half of the patients have preserved ejection fraction (EF>50%)(1). It is a major public health problem that is associated with increased mortality and morbidity. Heart Failure (HF) has classically been considered to be a Clinical Syndrome associated with Cardiac dilation and impaired cardiac contractility (2). Many studies showed that the majority of patients with heart failure have normal Ejection fraction .This has variously been labeled as Diastolic Heart Failure, ―Heart Failure with Preserved Ejection Fraction‖(HFPEF)(1) or― Heart Failure with normal Ejection Fraction‖(HFnlEF)(6) and is attributed to abnormalities of Diastolic function although the exact mechanism is debated(4,5). The epidemiology, aetiology and pathophysiology of this condition are reviewed recently.In epidemiological surveys, the prognosis of HFpEF is nearly as poor as for heart failure with reduced ejection fraction (HFrEF)(1). Prior data suggest that patients who have HF with Preserved Ejection Fraction tend to be older, to be female and to have a history of Hypertension (HT)(7,8). The EF threshold (or ―cutoff‖) value used to differentiate the Heart Failure patients as Reduced EF and Normal or Preserved EF ranged from 40% to 50% in avariety of studies. What is the idea threshold value? Data indicate that patients with an EF between 40% and 50% behave more like patients with EF 40%. The major conclusions of Smith et al.(9) would not be changed if the EF cutoff was >50% instead of >40%. Therefore, it is reasonable to conclude that the ideal cutoff to differentiate Reduced EF from Preserved EF is 50%.
Although there is increase in prevalence of HF with preserved Ejection Fraction, studies on Indian population are few, so we conducted a study in our hospital to know the clinical and echo profile in HF with Preserved Ejection Fraction over a period of two years.
Aims and objectives :
To study the clinical features, risk factors and echo profile in patients with suspected heart failure with preserved ejection fraction.
Review of literature :
1. Heart Failure: The newly proposed universal definition of heart Failure describes it as a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion(3) . A revised classification(3) of Heart Failure by using left ventricular ejection fraction (LVEF) was also proposed and is as follows:
● Heart failure with reduced ejection fraction (HFrEF) – symptomatic HF with LVEF ≤40%.
● Heart failure with mildly reduced ejection fraction (HFmrEF) – symptomatic HF with LVEF 41-49%.
● Heart failure with preserved ejection fraction (HFpEF) – symptomatic HF with LVEF ≥50%
● Heart Failure with improved ejection fraction (HFimpEF) – it is a new classification which is distinctly defined as symptomatic HF with a baseline LVEF ≤40%, a ≥10-point increase from baseline LVEF, and a second measurement of LVEF >40% .
PATIENTS AND METHODS :
STUDY DESIGN : Observational Prospective study
STUDY DURATION : OCTOBER 2019 - SEPTEMBER 2021
SAMPLE SIZE : 50 patients
ETHICAL COMMITTEE APPROVAL : Obtained
PATIENT CONSENT : Informed consent was obtained
FINANCIAL SUPPORT : Nil
CONFLICT OF INTEREST : Nil
Wee conducted a study including 50 patients who came to our hospital during 2019- 2021.
All the patients were evaluated with
1. Thorough History
2. Complete Physical Examination
3. Chest X-Ray
4. ECG
5. Complete Blood Count
6. Renal Function Test
7. Fasting Blood Sugar
8. Lipid Profile
9. Serum Albumin
10. Pulmonary Function Test
Afterr routine investigations 2D echo was done.
Inclusion Criteria:
1. All patients with Signs and Symptoms of Heart Failure who fulfills the Framingham Criteria.
2. All age groups more than 12 yrs. Exclusion Criteria:
All confirmed cases of
1. Valvular Heart Disease
2. Congenital Heart Disease
3. Patients with CorPulmonale.
OBSERVATION AND RESULTS:
50 Patients of Heart failure with preserved ejection fraction were analyzed.
DISCUSSION :
Heartt Failure with preserved ejection fraction is now a growing epidemic. Although there is increased prevalence ,a little is known about the exact pathophysiology and management . Despite these challenges, recognition of HFpEF is increasing, and diagnostic algorithms for HFpEF are maturing, with the availability of both the H2FPEF and HFA-PEFF. The H2FPEF score, in particular, could be used in primary care settings to screen at-risk patients. Both of these scores advocate for exercise testing when clinical criteria are indeterminate. Although these scores should enhance recognition and provide more systematic diagnosis of HFpEF, multiple challenges remain, and further studies with simpler and more broadly applicable methods (eg, novel biomarkers) were considered a key priority. However there was a proposed hypothesis that HFPEF was a continuum of HFrEF,Serial prospective studies showed it was observed in less than 2% of the population. Almost half of all patients with HF have preserved ejection fraction. The risk factors, clinical features, pathophysiology and course of the illness are been studied recently. Fewer studies were done on Indian population to study about patient profile and echocardiographic changes in Hfpef. This study was conducted with all patients who presented to our hospital with features suggesting heart failure. Detailed history, examination and investigations like Ecg, echocardiography was done to study patient profile, and echocardiographic changes. In the present study 50 patients of heart failure fulfilling Framingham criteria who were admitted in the General Medical Ward in Kamineni Institute of medical sciences, Nalgonda during the period between October 2019 to September 2021 were studied.
Most of the patients had similar presentations, the most common presenting symptom was breathlessness. Echocardiography was needed to determine Ejection Fraction and to distinguish from HFREF. Detailed study was done in all HFPEF patients with regards to the clinical features, Risk factors and echocardiographic profile. Men >56years of age were more affected, unlike other studies where female predominance was reported .AF did not show significance in HFPEF (10%) whereas Theophilus E Owan et al.(34) studies showed that it was significant in HFPEF(41%). SHT, CAD and DM were the most common risk factors in HFPEF patients . Highest being Systolic HTN seen in 86 % of patients. Vasan et al(5) studies showed mean SBP was 143±24 mmHg and DBP was 73±13mmHg in HFPEF whereas present study showed mean SBP was144±29mmHg and mean DBP was 86.8±15mmHg in patients with HFPEF. Left ventricular hypertrophy was the most common ECG finding seen in 58 % of patients.ECG evidence of IHD was26% in patients with HFPEF. Pulmonary venous hypertension on CXR was present in 80% of patients with HFPEF.
CONCLUSION :
1. 50 Patients of Heart failure with preserved ejection fraction were analyzed. 2. Mean age of patients in HFPEF was 48± 10.7 for males, 45.5± 11.36 for females.
3. Men with the age of 56 yrs and above (32%) were mostly affected with HFPEF.
4. Exertional Breathlessness was the most common presenting symptom (86%) .Pedal edema was seen in 90% of patients, next most common sign was raised JVP seen in 82% .
5. SHT was the most common risk factor in HFPEF (86%) of patients followed by Alcohol (46%) and CAD (36%).
6. LVH was the most common manifestation in ECG seen in 58% in HFPEF. Evidence of IHD was seen in 26% in HFPEF. AF was seen in 10% of HFPEF
7. Pulmonary venous hypertension on CXR was seen in 88% , followed by cardiomegaly seen in 72% .
8. Observed E/A ratio were reduced to below one in HFPEF (Mean was 0.83).
9. Diastolic dysfunction was seen in 96 % of patients, most of them had Grade 1 diastolic dysfunction.
10. Left Atrial enlargement which serves as surrogate marker for increased LVEDP was seen in 52% of patients with HFPEF. 11. Mean Ejection fraction in HFPEF patients was 58±4.1%.
Link to Entire Thesis Document :
https://docs.google.com/document/d/13bQsm_Y-Kp40QjKrIHTtc9dsZzHYZ1C8wti2DJDkn6U/edit?usp=drivesdk
Link to master chart :
Comments
Post a Comment