The Management of Heart Failure with Preserved Ejection Fraction
Heart failure is defined as a clinical syndrome and is known to present with a number of different pathophysiological patterns. There is a remarkable degree of variation in measures of left ventricular systolic emptying and this has been used to categorise heart failure into two separate types: low ejection fraction (EF) heart failure or HF-REF and high EF heart failure or HF-PEF. Here we review the pathophysiology, epidemiology and management of HF-PEF and argue that sharp separation of heart failure into two forms is misguided and illogical, and the present scarcity of clinical trial evidence for effective treatment for HF-PEF is a problem of our own making; we should never have excluded patients from major trials on the basis of EF in the first place. Whilst as many heart failure patients have preserved EFs as reduced, we have dramatically under-represented HF-PEF patients in trials. Only four trials have been performed in HF-PEF specifically, and another two trials that recruited both HF-PEF and HF-REF can be considered. When we consider the similarity in outcomes and neurohormonal activation between HF-REF and HF-REF, the vast corpus of trial data that we have to attest to the efficacy of various treatment (angiotensin-converting-enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], beta-blockers and aldosterone antagonists) in HF-REF, and the much more limited number of trials of similar agents showing near statistically significant benefits in HF-PEF the time has come rethink our management of HF-PEF, and in particular our selection of patients for trials.
Andrew JS Coats
- The epidemiology of HFpEF
- The clinical trials in HFpEF
- Why we have not improved prognosis in HFpEF despite many improvements in HFrEF
- Cardiologists in training
- General practitioners with an interest in cardiology
- Age care physicians
Andrew JS Coats
Prof Coats is Joint Academic Vice-President of Monash University, Australia and the University of Warwick, UK. His research greatly influenced the treatment for chronic heart failure, promoting exercise training instead of bed rest. He has a vast experience in education and publishing.
Prof Coats attended Melbourne Grammar School and studied at Oxford and Cambridge. He has a higher doctorates from Oxford (DM) and Imperial (DSc.). He was appointed Viscount Royston Professor of Cardiology at Imperial College in 1996 and Director of Cardiology and Associate Medical Director of the Royal Brompton and Harefield NHS trust. Prof Coats was appointed Dean of Medicine at the University of Sydney in 2002, and subsequently Deputy Vice-Chancellor. He was most recently CEO of the Norwich Research Park, the UK's oldest and largest research and innovation park.
His research interests are chronic heart failure, hypertension, and organizational behaviour. Prof Coats has a MBA from London Business School, is a Diplomate and Fellow of the Australian Institute of Company Directors and member of the UK Institute of Directors.
Prof Coats is the Editor-in-Chief of Cardiac Failure Review Journal.
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