![Large peridevice leaks after left atrial appendage occlusion (LAAO) are incredibly rare and not associated with a greater risk of adverse outcomes, according to new research published in JACC: Clinical Electrophysiology.[1] Smaller residual links are more common, however, and associated with a risk of thromboembolic and bleeding events.](/sites/default/files/styles/top_stories/public/2018-08/olderpatient-doctor.jpg.webp?itok=Cv18wcDr)
The American College of Cardiology (ACC) has issued two new guidance documents focused on the treatment and management of heart failure with preserved ejection fraction (HFpEF).
The first is an expert consensus decision pathway that details every step of the care process for patients with suspected HFpEF.[1] The writing committee behind the document—led by Michelle M. Kittleson, MD, PhD, a professor of medicine with Cedars-Sinai and director of heart failure research at the Smidt Heart Institute—explained that heart failure continues to be a significant cause of death in the United States despite key advances in both technology and treatment techniques. The hope is that this new expert consensus decision pathway can provide cardiologists and other members of the heart team with a new resource for improving patient care and delivering better outcomes.
“Although the incidence of overall heart failure in the United States appears to be stable or even declining, the incidence of HFpEF continues to rise,” the group wrote. “HFpEF now accounts for more than 50% of cases of heart failure, with outcomes comparable to heart failure with reduced ejection fraction (HFrEF). HFpEF is often under-recognized and results in substantial resource utilization.”
Diagnosing patients with HFpEF
One of the document’s key topics is the diagnosis of HFpEF. The writing group explained that either two or more major criteria or one major criterion and two minor criteria are “strictly required” to make a HFpEF diagnosis. The list of major criteria included orthopnea, jugular venous distension, hepatojugular reflux, rales, S3 gallop rhythm, acute pulmonary edema and cardiomegaly. The list of minor criteria includes dyspnea (shortness of breath) on exertion, nocturnal cough, ankle edema, tachycardia with a heart rate over 120 BPM, hepatomegaly and pleural effusion.
Before finalizing a HFpEF diagnosis in a patient with dyspnea, the team added, cardiologists should rule out other potential sources of the issue. Just like chest pain, dyspnea is a symptom that often results in patients visiting an emergency room or hospital—rushing to make a diagnosis can result in wasted healthcare resources and unnecessary treatments.
The writing group also detailed two scoring systems, H2FPEF and HFA-PEFF, capable of helping clinicians determine if HFpEF is the most likely explanation of a patient’s symptoms. While the H2FPEF score is quicker to use, relying on easy-to-access patient data, the HFA-PEFF score is “more involved” and will typically require a hemodynamic assessment of the patient in question.
Both scores “can aid clinicians in diagnosing HFpEF,” the group wrote, but each one also has certain limitations, which are summarized in the guidance document
The power of patient referrals and team-based care
When primary care clinicians believe a patient is suffering from HFpEF, the writing group explained, referring that patient to a cardiovascular specialist is a key step. If the primary care clinician is unsure, there is an acronym—CHECK-IN—that can help know what to look for as they decide. The acronym stands for Collaboration, High-risk features, Extensive evaluation, Cardiorenal syndrome, Knowledge of HFpEF mimics, Increased need for diuretic agents, NYHA Class III or IV symptoms.
Another acronym, INHALE (In need of diagnosis, Nonresponsive to diuretic agents or medical therapy, Hospitalized frequently for heart failure, Acute or chronic end-organ dysfunction, Low blood pressure, Evidence of HFpEF mimics), can then help cardiovascular specialists know when a heart failure specialist may be required.
The document also focuses on the importance of team-based care when treating these patients.
“Regardless of the size and composition of the team, a team-based approach requires a clear understanding of each team member’s functions and responsibilities, communication across disciplines, and the use of shared decision-making that is culturally appropriate,” according to the writing group. “Requisite skills for the care team include establishing the diagnosis and monitoring for improvement or exacerbations, prescription of medical and lifestyle interventions, educating individuals and their informal caregivers, and coordinating care among team members and other clinicians external to the care team. Team-based programs should be systematically developed and include monitoring of effectiveness, with a clear plan for correcting identified deficiencies.”
The full expert consensus decision pathway, which covers much more ground than is mentioned here, was published in the Journal of the American College of Cardiology.
A new scientific statement
The second new ACC document related to this topic is a new scientific statement designed to review crucial definitions and explain the latest research on HFpEF.[2] First author Barry A. Borlaug, MD, a heart failure specialist with Mayo Clinic, and colleagues also noted that a “systematic laboratory investigation” of patients with HFpEF is essential for ensure they receive the best care possible. In addition to a complete blood cell count and a chemistry panel, clinicians should also use tools such as liver function tests, iron studies and autoimmune panel to provide a complete picture of the patient’s health.
Blood control and weight loss can also be highly effective in the treatment of these patients, though medications such as empagliflozin and dapagliflozin may also be beneficial. Exercise training and pulmonary artery pressure monitoring are two other treatment options heart teams may want to consider.
Borlaug et al. also highlighted recent progress in the field of HFpEF care and looked head to the future.
“We now understand that HFpEF is a systemic, ‘reserve dysfunction’ syndrome that involves multiple organs, not just the heart, and one that often requires perturbational testing to assist with diagnosis and treatment selection,” the authors wrote. “Improved understanding of HFpEF in this manner has expanded the potential treatment landscape beyond conventional heart failure therapies to those that have beneficial effects in multiple organs. Indeed, a likely reason for the broad success of SGLT2i is the ability to improve the metabolic health of multiple organs while also promoting renoprotective diuresis. Successful future therapeutics will likely fall into one of two categories: 1) broadly applicable therapeutics such as SGLT2i that ameliorate abnormalities in multiple organs; and 2) tailored therapies that are directed toward specific subtypes of HFpEF (ie, a precision medicine approach to HFpEF).”
Read the full scientific statement in the Journal of the American College of Cardiology here.
Michael has more than 16 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.