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Research

The tip of the iceberg: finding patients with heart failure with preserved ejection fraction in primary care. An observational study

Christi Deaton, Duncan Edwards, Alexandra Malyon and M Justin S Zaman
BJGP Open 2018; 2 (3): bjgpopen18X101606. DOI: https://doi.org/10.3399/bjgpopen18X101606
Christi Deaton
1 Florence Nightingale Foundation Clinical Professor of Nursing, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, , UK
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  • For correspondence: cd531@medschl.cam.ac.uk
Duncan Edwards
2 NIHR Doctoral Research Fellow, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, , UK
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Alexandra Malyon
3 Clinical Research Development Nurse, Department of Education and Research, Cambridge University Hospital, , UK
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M Justin S Zaman
4 Consultant Cardiologist, Department of Medicine, James Paget University Hospital, , UK
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Article Figures & Data

Tables

    • View popup
    Box 1. Recommended echocardiographic indices for diagnosing HFpEF and diastolic dysfunction
    European Society of Cardiology clinical practice guidelines on acute and chronic heart failure 20163
    Relevant structural heart disease
    • Left ventricular hypertrophy (left ventricular mass index >115 g/m2 for males and >95 g/m2 for females)

    • Left atrial enlargement (left atrial volume index >34 mL/m2)

    Diastolic dysfunction
    • Early diastolic tissue velocity (e’ mean septal-lateral <9 cm/sec)

    • Ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E/e’>13)

    • Deceleration time (DecT) of mitral valve early diastolic inflow (MV-E) m/sec

    • E/A ratio <1 or >2

    • Isovolumetric relaxation time (IVRT)

    American Society of Echocardiography and the European Association of Cardiovascular Imaging 2016 9
    Annular e’ velocity
    • Septal e’ <7 cm/sec

    • Lateral e’ <10 cm/sec

    Average E/e’ ratio >14
    Left atrium maximum volume index (>34 mL/m2)
    Peak tricuspid regurgitation velocity >2.8 m/sec

    Note: LV diastolic function is normal if more than half of the variables do not meet the cut-off for identifying abnormal function.

    cm/sec = centimetres per second. E = early mitral diastolic inflow. e’ = early diastolic tissue velocity. E/A = ratio between peak early (E) and late (A) diastolic filling velocities. E/e’ = ratio between early mitral inflow velocity and mitral annular early diastolic velocity. g/m2 = grams per metre squared. LV = left ventricle. m/sec = metres per second. mL/m2 = millilitres per metre squared. MV = mitral valve.

      • View popup
      Table 1. Characteristics of sample
      Patients on heart failure registers (n = 148)
      Age, years76.9 + 12
      Duration of heart failure diagnosis, years5.3 + 4
      Female sex, %39
      Hypertension, %84
      Chronic kidney disease, %44
      Atrial fibrillation, %41
      BMI 25–29.9 kg/m2,%31
      BMI >30 kg/m2, %39
      Ischaemic heart disease, %32
      Diabetes, %25
      Valvular heart disease, %22
      COPD, %16
      Stroke, %15
      Asthma, %10
      Current smoker, %10
      Ex-smoker, %30
      Echocardiogram information available, %79
      • COPD = chronic obstructive pulmonary disease, HF = heart failure; kg/m2 = kilograms per metre squared

      • View popup
      Table 2. Clinical characteristics by EF group
      CharacteristicsEF <40%
      (n = 43)
      EF 40–49%
      (n = 21)
      EF >50%
      (n = 53)
      Unclear or missing
      (n = 31)
      P value
      Mean age (SD)76 (13)76 (13)79.8 (11)74.2 (11)0.161
      Female sex, %302945460.293
      Hypertension, %808183930.442
      IHD, %392930290.743
      CKD, %393851420.615
      Diabetes, %241032260.254
      AF, %494347190.048
      COPD, %121019190.638
      Stroke, %151417130.964
      Valvular heart disease, %24242870.123
      BMI 25–29.9 kg/m2, %331834300.630
      BMI >30 kg/m2, %332947400.503
      >3 comorbidities, %514165630.270
      Mean duration of HF, years (SD)4.3 (4.5)5.9 (4.4)5.0 (4.0)6.9 (5.0)0.08
      • AF = atrial fibrillation. BMI = body mass index. CKD = chronic kidney disease. COPD = chronic obstructive pulmonary disease. EF = ejection fraction. HF = heart failure. IHD = ischaemic heart disease. Kg/m2 = kilograms per metre squared. SD = standard deviation.

      • View popup
      Table 3. Echocardiographic data in 39 patients with EF >50%
      EF >50%a
      Mean EF (SD)57 +5%
      At least one recommended measure of structural heart disease documented, n/N (%)35/39 (90)
      LVH present, n/N (%)16/35 (46)
      Concentric LVH, n/N (%)6/16 (38)
      LA dilated, n/N (%)28/33 (85)
      Both LV and LA normal n/N (%)7/39 (18)
      At least one recommended index of diastolic function measured, n/N (%)24/39 (62)
      E/A ratio, n/N (%)13/24 (54)
      e' lateral, n/N (%)5/24 (21)
      e' septal, n/N (%)5/24 (21)
      E/e' mean, n/N (%)19/24 (79)
      TRV, n/N (%)14/24 (58)
      At least one recommended index of diastolic function is abnormal, N/n (%)17/24 (71)
      Number of diastolic function indices that are abnormal
      One8
      Two5
      Three3
      Four1
      Diastolic dysfunction labelled on report or in letter where diastolic function mentioned, n/N (%)11/20 (55)
      RV dysfunction present, n/N (%)7/31 (23)
      RV dilation, n/N (%)9/27 (33)
      PH documented, n/N (%)7/26 (27)
      • aincludes patients labelled as having a ‘normal’, ‘near-normal’ or ‘preserved’ EF

      • E/A = ratio between peak early (E) and late (A) diastolic filling velocities. EF = ejection fraction. e’ = early diastolic tissue velocity. E/e’ = ratio between early mitral inflow velocity and mitral annular early diastolic velocity. LA = left atrium. LV = left ventricle. LVH = left ventricular hypertrophy. PH = pulmonary hypertension. RV = right ventricle. TRV = peak tricuspid regurgitation velocity.

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    The tip of the iceberg: finding patients with heart failure with preserved ejection fraction in primary care. An observational study
    Christi Deaton, Duncan Edwards, Alexandra Malyon, M Justin S Zaman
    BJGP Open 2018; 2 (3): bjgpopen18X101606. DOI: 10.3399/bjgpopen18X101606

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    The tip of the iceberg: finding patients with heart failure with preserved ejection fraction in primary care. An observational study
    Christi Deaton, Duncan Edwards, Alexandra Malyon, M Justin S Zaman
    BJGP Open 2018; 2 (3): bjgpopen18X101606. DOI: 10.3399/bjgpopen18X101606
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    Keywords

    • heart failure with preserved ejection fraction
    • diagnosing heart failure
    • echocardiogram
    • heart failure
    • diagnostic tests
    • delayed diagnosis

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