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

doi:10.3399/bjgpopen18X101606

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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.

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Table 1. Characteristics of sample

	Patients on heart failure registers (n = 148)
Age, years	76.9 + 12
Duration of heart failure diagnosis, years	5.3 + 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

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Table 2. Clinical characteristics by EF group

Characteristics	EF <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, %	30	29	45	46	0.293
Hypertension, %	80	81	83	93	0.442
IHD, %	39	29	30	29	0.743
CKD, %	39	38	51	42	0.615
Diabetes, %	24	10	32	26	0.254
AF, %	49	43	47	19	0.048
COPD, %	12	10	19	19	0.638
Stroke, %	15	14	17	13	0.964
Valvular heart disease, %	24	24	28	7	0.123
BMI 25–29.9 kg/m², %	33	18	34	30	0.630
BMI >30 kg/m², %	33	29	47	40	0.503
>3 comorbidities, %	51	41	65	63	0.270
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.

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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
One	8
Two	5
Three	3
Four	1
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.