Ejection fraction is back to normal—now what?

,

Applied Evidence

Ejection fraction is back to normal—now what?

J Fam Pract. 2010 March;59(3):142-147

By

William E. Chavey, MD, MS

Heart failure treatment guidelines don’t address whether to change a patient’s medications should the EF improve. This evidence review provides guidance.

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References

1. Schocken DD, Benjamin EJ, Fonarow GC, et al. American Heart Association Council on Epidemiology and Prevention; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Nursing; American Heart Association Council on High Blood Pressure Research; Quality of Care and Outcomes Research Interdisciplinary Working Group; Functional Genomics and Translational Biology Interdisciplinary Working Group Prevention of heart failure: a scientific statement from the American Heart Association Councils on Epidemiology and Prevention, Clinical Cardiology, Cardiovascular Nursing, and High Blood Pressure Research; Quality of Care and Outcomes Research Interdisciplinary Working Group; and Functional Genomics and Translational Biology Interdisciplinary Working Group. Circulation. 2008;117:2544-2565.

2. Quinones MA. Assessment of diastolic dysfunction. Prog Cardiovasc Dis. 2005;47:340-355

3. Smiseth OA, Thompson CR. Atrioventricular filling dynamics, diastolic dysfunction and dysfunction. Heart Fail Rev. 2000;5:291-299.

4. Pinamonti B, Zecchin M, DiLenarda A, et al. Persistence of restrictive left ventricular filling pattern in dilated cardiomyopathy: an ominous prognostic sign. J Am Coll Cardiol. 1997;29:604-612.

5. Yamamoto K, Sakata Y, Ohtani T, et al. Heart failure with preserved ejection fraction—what is known and unknown. Circ J. 2009;73:404-410.

6. Task Force for Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of European Society of Cardiology, Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008. Eur Heart J. 2008;29:2388-2442.

7. Jessup M, Abraham WT, Casey DE, et al. Focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009;199:1977-2016

8. Chavey WE, Bleske BE, Van Harrison R, et al. Pharmacologic management of heart failure caused by systolic dysfunction. Am Fam Physician. 2008;77:957-968.

9. Joint Commission Heart failure core measure set. Oak-brook Park, IL. Available at: http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Heart+Failure+
Core+Measure+Set.htm. Accessed February 5, 2010.

10. Yusuf S, Pfeffer MA, Swedberg K, et al. Effects of candesartan in patients with chronic heart failure and preserved ejection fraction: the CHARM-Preserved Trial. Lancet. 2003;362:777-781.

11. Moreo A de Chiara B, Cataldo G, et al. Prognostic value of serial measurements of left ventricular function and exercise performance in chronic heart failure [in Spanish]. Rev Esp Cardiol. 2006;59:905-910.

12. Metra M, Nodari S, Parrinello G, et al. Marked improvement in left ventricular ejection fraction during long-term beta blockade in patients with chronic heart failure: clinical correlates and prognostic significance. Am Heart J. 2003;145:292-299.

13. Swedberg K, Cleland J, Dargie H, et al. For the Task Force for the Diagnosis and Treatment of Chronic Heart Failurwe of the European Society of Cardiology. Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005). Eur Heart J. 2005;26:1115-1140.

14. Malm S, Frigstad S, Sagberg E, et al. Accurate and reproducible measurement of left ventricular volume and ejection fraction by contrast echocardiography. J Am Coll Cardiol. 2004;44:1030-1035.

15. McGowan JH, Cleland J. Reliability of reporting left ventricular systolic function by echocardiography: a systematic review of three methods. Am Heart J. 2003;146:388-397.

16. Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography. J Am Soc Echocardiogr. 2005;18:1440-1463.

17. Moon J, Ko YG, Chung N, et al. Recovery and recurrence of left ventricular systolic dysfunction in patients with idiopathic dilated cardiomyopathy. Can J Cardiol. 2009;25:e147-e150.

18. Cioffi G, Stefenelli C, Tarantini L, et al. Chronic left ventricular failure in the community: prevalence, prognosis, and predictors of the complete clinical recovery with return of cardiac size and function to normal in patients undergoing optimal therapy. J Card Fail. 2004;10:250-257.

19. Di Lenarda A, Sabbadini G, Perkan A, et al. Apparent healing in dilated cardiomyopathy: incidence, long-term persistence and predictive factors. The heart muscle disease registry of Trieste [abstract]. Ital Heart J. 2001;2(suppl 2):S97.-

PRACTICE RECOMMENDATIONS

• Assess the ejection fraction (EF) of all heart failure patients, and treat those with reduced EF according to established guidelines. A

• Reassess EF only when the clinical situation demands it; there is no need for routine EF surveillance. B

• Continue to treat patients with heart failure medications even after their EF has normalized. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE Joe H is a 64-year-old African American man with a history of heart failure, hypertension, coronary artery disease (CAD), type 2 diabetes, chronic kidney disease, atrial fibrillation, and gout. His ejection fraction (EF), measured several years ago by echocardiography, was 20%, and he has New York Heart Association class II–III symptoms. Joe is taking an angiotensin-converting enzyme (ACE) inhibitor, a beta-blocker, an aldosterone antagonist, a loop diuretic, a nitrate, and digoxin, and he has an implantable cardioverter defibrillator (ICD). He recently spent 2 days in the hospital after being admitted for chest pain.

As an inpatient, Joe underwent stress echocardiography, which showed no inducible ischemia and an EF of 50%. Should the normalization of Joe’s EF prompt a change in his therapy?

Heart failure (HF), which affects an estimated 5 million Americans, is the leading cause of hospitalization in people older than 65 years.¹ The condition—characterized by signs and symptoms of congestion and objective evidence of structural or functional heart disease—has historically been divided into 2 categories: Patients with HF and a reduced ejection fraction (EF) were said to have systolic dysfunction, while the term “diastolic dysfunction” was applied to those with HF and a preserved EF.

The distinction between systolic and diastolic dysfunction is not so simple, though, and the definition of diastolic dysfunction, in particular, is not so clearcut.

Diastolic dysfunction is sometimes described on the basis of echocardiographic criteria, such as the ratio of early-to-late diastolic filling, short deceleration times, and isovolumic relaxation times.^2,3 But demographic and physiologic variables make interpretation of these parameters difficult, and the parameters themselves are not uniformly applied. What’s more, echocardiographic evidence of diastolic dysfunction is not specific to HF with a preserved EF.⁴ Some patients may be shown to have diastolic dysfunction and reduced EF.

As understanding of these variations grows, momentum about the need to change the clinical terminology has begun to develop. The suggested revision is simply to distinguish between HF with reduced EF and HF with preserved EF.⁵

To provide the best possible care for HF patients—including those who, like Joe, have gone from a reduced to a normal EF after receiving aggressive treatment—you need to be familiar with these changing parameters, recent research findings, and implications for treatment.

Managing both types of HF: What the evidence shows

Evidence-based management of HF with reduced EF is distinctly different from that of HF with preserved EF (TABLE).^6-8 In fact, the vast majority of the evidence involves patients with reduced EF, as most randomized clinical trials (RCTs)—and the only trials demonstrating a reduction in mortality—have excluded patients with preserved EF. Thus, in diagnosing and treating HF patients, it is crucial to assess for, and to distinguish between, the 2 EF states. Documentation of this assessment is a core quality measure for HF management, according to the Joint Commission.⁹

FAST TRACK

In symptomatic patients with a preserved ejection fraction, an angiotensin receptor blocker has been found to reduce hospital admission rates.

Treating HF with reduced EF. Barring any contraindications, ACE inhibitors and beta-blockers are core treatments for patients with reduced EF.⁸ Aldosterone antagonists are also indicated for patients with reduced EF who have, or recently had, rest dyspnea. They are also indicated for patients with reduced EF who are 3 to 14 days post-MI and have diabetes or symptomatic HF.⁸ Nitrates are indicated for African American patients who have persistent symptoms despite treatment with ACE inhibitors, beta-blockers, and diuretics, as needed.⁸ Consider an ICD as well, as these devices have been found to significantly reduce the risk of death for patients who have an EF <35% with either ischemic cardiomyopathy or symptomatic HF.

FAST TRACK

Closely monitor HF patients taking an aldosterone antagonist for renal function and potassium disturbances.

Treating HF with preserved EF. Because of the dearth of trials involving patients with HF and a preserved EF, there is limited evidence-based treatment. Nonetheless, it is reasonable to control signs and symptoms of congestion with diuretics.⁶ In addition, the CHARM-Preserved trial demonstrated the efficacy of candesartan—an angiotensin receptor blocker—in decreasing rates of hospital admissions among symptomatic patients with a preserved EF.¹⁰