This transcript has been edited for clarity.
Hello. This is Ileana Piña, and this is my blog. I'm here at the American College of Cardiology meeting where there is an electric buzz — and everyone can feel it — from the ability to be together again for the end of that terrible COVID-19 era that we have lived through, even though COVID-19 is still around. It hasn't gone away but some of the parameters have changed. It's really good to be together, seeing all of my friends.
I want to talk to you about that definition of heart failure. We've done this before in the blog. We have talked about the definition of heart failure, and remember, that it's not just that ejection fraction. It's also things like N-terminal pro b-type natriuretic peptide and signs of congestion. Congestion may be looked at on a chest x-ray, a CT scan, or a good physical exam that shows congestion to confirm the presence of heart failure.
We've come a long way. Now we've defined the pieces, the slicing and the dicing of the ejection fraction. We used to say that 40% or less — well, maybe actually 35% or less — was the low or the reduced ejection fraction. That's how we started with the heart failure with reduced ejection fraction (HFrEF). Then we were calling anything over 40% HF with preserved EF (HFpEF).
We have learned from the trials.
Maybe true HFpEF doesn't really start until 50% or higher. I think the best example of that is the PARAGON-HF trial, where the point estimates change when you get to those higher EFs.
Maybe the real HFrEF is anything below 50%. Maybe it's mild HFrEF, but now we call it mid-range EF (mrEF). In the slicing and the dicing, we have come to agree that somewhere between 40% and 49% or 35% and 49% could be the mid-range. Our European colleagues started calling it that.
Then there's that other group of the patients who have improved, the patients who had severe HFrEF and because of the medical therapy, have gotten better. Their EFs may have almost normalized, even though, maybe, they don't really truly normalize. They're certainly not 20% or 25% anymore. Maybe they're 40%. Maybe they're 45%. We think that may be a different group, again, another slicing and dicing. Those are called the improved, the "imps."
Why am I bringing all this out? When you're doing your clinic visit and you are writing down that physical examination and you finish your note with an assessment and a plan, call it what it is. Right now, Medicare doesn't recognize any of these other separations. They still call it systolic and diastolic, even though I hear that the ICD-12s may be coming out very differently.
Put it in your note. I start my note saying, this is HFrEF, HFpEF, or mrEF. Why? It makes you think of what you need to do with that designation and the patient that's in front of you.
Our goal is to get the right drugs to the right patient, at the right time, for the right reason. Isn't that our definition of quality? I think it is.
Thank you for joining me today. This is Ileana Piña, signing off.
Ileana L. Piña, MD, MPH, is a heart failure and cardiac transplantation expert. She serves as an advisor/consultant to the FDA's Center for Devices and Radiological Health and has been a volunteer for the American Heart Association since 1982. Originally from Havana, Cuba, she is passionate about enrolling more women and minorities in clinical trials. She also enjoys cooking and taking spin classes.
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Cite this: Ileana L. Piña. Defining Heart Failure: EF Slicing and Dicing - Medscape - May 05, 2023.
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