Diagnosis of patients with heart failure with preserved ejection fraction in primary care : Cohort study

Aims Heart failure with preserved ejection fraction (HFpEF) accounts for half of all heart failure (HF), but low awareness and diagnostic challenges hinder identification in primary care. Our aims were to evaluate the recruitment and diagnostic strategy in the Optimise HFpEF cohort and compare with recent recommendations for diagnosing HFpEF. Methods and results Patients were recruited from 30 primary care practices in two regions in England using an electronic screening algorithm and two secondary care sites. Baseline assessment collected clinical and patient-reported data and diagnosis by history, assessment, and trans-thoracic echocardiogram (TTE). A retrospective evaluation compared study diagnosis with H2FPEF score and HFA-PEFF diagnostic algorithm. A total of 152 patients (86% primary care, mean age 78.5, 40% female) were enrolled; 93 (61%) had HFpEF confirmed. Most participants had clinical features of HFpEF, but those with confirmed HFpEF were more likely female, obese, functionally impaired, and symptomatic. Some echocardiographic findings were diagnostic for HFpEF, but no difference in natriuretic peptide levels were observed. The H2FPEF and HFA-PEFF scores were not significantly different by group, although confirmed HFpEF cases were more likely to have scores indicating high probability of HFpEF. Conclusions Patients with HFpEF in primary care are difficult to identify, and greater awareness of the condition, with clear diagnostic pathways and specialist support, are needed. Use of diagnostic algorithms and scores can provide systematic approaches to diagnosis but may be challenging to apply in older multi-morbid patients. Where diagnostic uncertainty remains, pragmatic decisions are needed regarding the value of additional testing versus management of presumptive HFpEF

Diagnosis of patients with heart failure with preserved ejection fraction in primary care: cohort study

Funder: NIHR Cambridge Clinical Research FacilityAbstract: Aims: Heart failure with preserved ejection fraction (HFpEF) accounts for half of all heart failure (HF), but low awareness and diagnostic challenges hinder identification in primary care. Our aims were to evaluate the recruitment and diagnostic strategy in the Optimise HFpEF cohort and compare with recent recommendations for diagnosing HFpEF. Methods and results: Patients were recruited from 30 primary care practices in two regions in England using an electronic screening algorithm and two secondary care sites. Baseline assessment collected clinical and patient‐reported data and diagnosis by history, assessment, and trans‐thoracic echocardiogram (TTE). A retrospective evaluation compared study diagnosis with H2FPEF score and HFA‐PEFF diagnostic algorithm. A total of 152 patients (86% primary care, mean age 78.5, 40% female) were enrolled; 93 (61%) had HFpEF confirmed. Most participants had clinical features of HFpEF, but those with confirmed HFpEF were more likely female, obese, functionally impaired, and symptomatic. Some echocardiographic findings were diagnostic for HFpEF, but no difference in natriuretic peptide levels were observed. The H2FPEF and HFA‐PEFF scores were not significantly different by group, although confirmed HFpEF cases were more likely to have scores indicating high probability of HFpEF. Conclusions: Patients with HFpEF in primary care are difficult to identify, and greater awareness of the condition, with clear diagnostic pathways and specialist support, are needed. Use of diagnostic algorithms and scores can provide systematic approaches to diagnosis but may be challenging to apply in older multi‐morbid patients. Where diagnostic uncertainty remains, pragmatic decisions are needed regarding the value of additional testing versus management of presumptive HFpEF

The effect of isometric exercise training on arterial stiffness: A randomized crossover controlled study.

Isometric exercise training (IET) is an effective intervention for the management of resting blood pressure (BP). However, the effects of IET on arterial stiffness remain largely unknown. Eighteen unmedicated physically inactive participants were recruited. Participants were randomly allocated in a cross-over design to 4 weeks of home-based wall squat IET and control period, separated by a 3-week washout period. Continuous beat-to-beat hemodynamics, including early and late systolic (sBP 1 and sBP 2, respectively) and diastolic blood pressure (dBP) were recorded for a period of 5 min and waveforms were extracted and analyzed to acquire the augmentation index (AIx) as a measure of arterial stiffness. sBP 1 (-7.7 ± 12.8 mmHg, p = 0.024), sBP 2 (-5.9 ± 9.9 mmHg, p = 0.042) and dBP (-4.4 ± 7.2 mmHg, p = 0.037) all significantly decreased following IET compared to the control period. Importantly, there was a significant reduction in AIx following IET (-6.6 ± 14.5%, p = 0.02) compared to the control period. There were also adjacent significant reductions in total peripheral resistance (-140.7 ± 65.8 dynes·cm-5, p = 0.042) and pulse pressure (-3.8 ± 4.2, p = 0.003) compared to the control period. This study demonstrates an improvement in arterial stiffness following a short-term IET intervention. These findings have important clinical implications regarding cardiovascular risk. Mechanistically, these results suggest that reductions in resting BP following IET are induced via favorable vascular adaptations, although the intricate details of such adaptations are not yet clear

The effect of isometric exercise training on arterial stiffness: A randomized crossover controlled study.

Isometric exercise training (IET) is an effective intervention for the management of resting blood pressure (BP). However, the effects of IET on arterial stiffness remain largely unknown. Eighteen unmedicated physically inactive participants were recruited. Participants were randomly allocated in a cross-over design to 4 weeks of home-based wall squat IET and control period, separated by a 3-week washout period. Continuous beat-to-beat hemodynamics, including early and late systolic (sBP 1 and sBP 2, respectively) and diastolic blood pressure (dBP) were recorded for a period of 5 min and waveforms were extracted and analyzed to acquire the augmentation index (AIx) as a measure of arterial stiffness. sBP 1 (-7.7 ± 12.8 mmHg, p = 0.024), sBP 2 (-5.9 ± 9.9 mmHg, p = 0.042) and dBP (-4.4 ± 7.2 mmHg, p = 0.037) all significantly decreased following IET compared to the control period. Importantly, there was a significant reduction in AIx following IET (-6.6 ± 14.5%, p = 0.02) compared to the control period. There were also adjacent significant reductions in total peripheral resistance (-140.7 ± 65.8 dynes·cm-5, p = 0.042) and pulse pressure (-3.8 ± 4.2, p = 0.003) compared to the control period. This study demonstrates an improvement in arterial stiffness following a short-term IET intervention. These findings have important clinical implications regarding cardiovascular risk. Mechanistically, these results suggest that reductions in resting BP following IET are induced via favorable vascular adaptations, although the intricate details of such adaptations are not yet clear

Left Atrial Mechanics Following Preeclamptic Pregnancy.

BACKGROUND: Preterm preeclampsia is a pregnancy complication associated with myocardial dysfunction and premature cardiovascular disease morbidity and mortality. Left atrial (LA) strain is a noninvasive index of left ventricular end diastolic pressure and an early marker of heart failure risk. This study aimed to evaluate LA strain during the postpartum period in participants with and without preterm preeclampsia and to assess whether this varied in the presence of hypertension and/or cardiac dysfunction. METHODS: In this longitudinal cohort study, 321 women from 28 hospitals with preterm preeclampsia (cases) underwent cardiovascular assessment 6 months postpartum. This is a secondary analysis of the PHOEBE study (ISRCTN01879376). An uncomplicated pregnancy control group (n=30) was recruited from a single center for comparison. A full cross-sectional transthoracic echocardiogram was performed, and from these images, the myocardial strain of the left atrium, including reservoir, conduit, and contractile strain, as well as LA stiffness, were calculated. RESULTS: At 6 months postpartum, compared with controls, prior preeclampsia was associated with a significantly attenuated LA reservoir, conduit, and contractile strain, as well as increased LA stiffness (all P<0.001). LA strain was further reduced in preeclamptic women who had and had not developed hypertension, systolic, or diastolic dysfunction at 6 months postpartum (all P<0.05). CONCLUSIONS: LA mechanics were significantly attenuated at 6 months postpartum in participants with preterm preeclampsia, whether or not they remained hypertensive or had evidence of ventricular dysfunction. Further studies are needed to determine whether postnatal LA strain may identify women at greater risk for future cardiovascular disease

Characteristics of Patients with Heart Failure with Preserved Ejection Fraction in Primary Care: Cross-sectional analysis

Background: Many patients with heart failure with preserved ejection fraction (HFpEF) are undiagnosed, and UK general practice registers do not typically record HF sub-type. Improvements in management of HFpEF is dependent on improved identification and characterisation of patients in primary care. Aims: To describe a cohort of patients recruited from primary care with suspected HFpEF and compare patients in whom HFpEF was confirmed and refuted. Design and Setting: Baseline data from a longitudinal cohort study of patients with suspected HFpEF recruited from primary care in two areas of England. Methods: A screening algorithm and review were used to find patients on HF registers without a record of reduced ejection fraction. Baseline evaluation included cardiac, mental and physical function, clinical characteristics and patient reported outcomes. Confirmation of HFpEF was clinically adjudicated by a cardiologist. Results: Ninety-three (61%) of 152 patients were confirmed HFpEF. The mean age of patients with HFpEF was 79.3, 46% were female, 80% had hypertension, and 37% took 10 or more medications. Patients with HFpEF were more likely to be obese, pre-frail/frail, report more dyspnoea and fatigue, were more functionally impaired, and less active than patients in whom HFpEF was refuted. Few had attended cardiac rehabilitation. Conclusions: Patients with confirmed HFpEF had frequent multimorbidity, functional impairment, frailty and polypharmacy. Although comorbid conditions were similar between people with and without HFpEF, the former had more obesity, symptoms and worse physical function. These findings highlight the potential to optimise well-being through comorbidity management, medication rationalisation, rehabilitation, and supported self-management.NIHR School for Primary Care Research NIHR Cambridge Biomedical Research Centr

Diagnosis of patients with heart failure with preserved ejection fraction in primary care: cohort study

Objectives: Heart Failure with preserved Ejection Fraction (HFpEF) accounts for half of all heart failure (HF), but low awareness and diagnostic challenges hinder identification in primary care. Our aims were to evaluate the recruitment and diagnostic strategy in the Optimise-HFpEF cohort and compare with recent recommendations for diagnosing HFpEF. Methods: Patients were recruited from 30 primary care practices in two regions in England using an electronic screening algorithm, and two secondary care sites. Baseline assessment collected clinical and patient-reported data and diagnosis by history, assessment and trans-thoracic echocardiogram (TTE). A retrospective evaluation compared study diagnosis with H2FPEF score and HFA-PEFF diagnostic algorithm. Results: 152 patients (86% primary care, mean age 78.5, 40% female) were enrolled; 93 (61%) had HFpEF confirmed. Most participants had clinical features of HFpEF, but those with confirmed HFpEF were more likely female, obese, functionally impaired and symptomatic. Some echocardiographic findings were diagnostic for HFpEF but no difference in natriuretic peptide levels were observed. The H2FPEF and HFA-PEFF scores were not significantly different by group, although confirmed HFpEF cases were more likely to have scores indicating high probability of HFpEF. Conclusions: Patients with HFpEF in primary care are difficult to identify and greater awareness of the condition, with clear diagnostic pathways and specialist support, are needed. Use of diagnostic algorithms and scores can provide systematic approaches to diagnosis but may be challenging to apply in older multi-morbid patients. Where diagnostic uncertainty remains, pragmatic decisions are needed regarding the value of additional testing versus management of presumptive HFpEF.NIHR School for Primary Care Research: Grant #384 NIHR Cambridge Biomedical Research Centre (BRC-1215-20014) and conducted at and supported by the NIHR Cambridge Clinical Research Facilit