Congestive heart failure life expectancy: Prognosis and stages
What Is Heart Failure With Preserved Ejection Fraction? Your FAQs Answered
Heart failure with preserved ejection fraction (HFpEF) occurs when the heart doesn't relax adequately. This is also known as diastolic heart failure.
Heart failure occurs when your heart doesn't pump enough blood to meet your body's needs or when the heart doesn't relax enough and pressures inside the chambers can rise. This can cause fatigue, breathing difficulties, and fluid buildup in your tissues.
According to the Centers for Disease Control and Prevention (CDC), an estimated 6.2 million U.S. Adults have heart failure. Roughly half of those people have HFpEF.
Read on to learn about HFpEF and get the answers to common questions about treatments, outlook, and more.
Heart failure with preserved ejection fraction (HFpEF) is a type of heart failure that occurs when the muscle in the left ventricle stiffens and is less able to relax, so the pressure inside the heart rises.
HFpEF is usually caused by:
To understand HFpEF, it helps to know how your heart works. Your heart is composed of four chambers:
The right atrium receives oxygen-depleted blood from the rest of your body and sends it to your right ventricle, which pumps the blood to your lungs to pick up oxygen.
The left atrium receives oxygen-rich blood from your lungs and sends it to your left ventricle, which pumps the blood to the rest of your body.
The movement of blood depends on the rhythmic relaxation and contraction of your heart chambers. This is known as the cardiac cycle.
In the cardiac cycle, there is a diastole and systole phase.
Your heart chambers (called ventricles) relax during the diastole phase of the cardiac cycle, which allows the heart chambers to fill with blood. Your heart muscle contracts during the systole phase, which pumps the blood.
If you have HFpEF, your left ventricle becomes stiff and can't relax properly. This prevents it from filling with enough blood during the cardiac cycle's diastole phase.
The filling occurs with higher pressure, which reduces the amount of blood available to pump throughout the body during the systole phase. This causes a backup of fluid into the lungs and the body.
As a result, less oxygen-rich blood is delivered to your organs and other tissues. Because of its high pressures, HFpEF can also cause fluid to build up in your tissues, which is known as congestive heart failure.
Heart failure with reduced ejection fraction (HFrEF) is also known as systolic heart failure. It also affects the left ventricle but in different ways.
In HFrEF, the left ventricle is too weak rather than too stiff. It cannot contract properly.
It may fill with enough blood during the cardiac cycle's diastole phase, but it can't pump that blood with enough force during the systole phase, so the amount of blood ejected (ejection fraction) is reduced.
Ejection fraction is a measurement that compares the amount of blood that fills your ventricle to the amount of blood that your ventricle pumps out with each contraction.
A typical ejection fraction is 55–70%. If your ejection fraction is below 50%, you may have HFrEF.
If you have HFpEF, you may actually have a typical ejection fraction. That's because there's less blood coming into the stiffened left ventricle, but your heart can still pump that blood back out of the ventricle.
Though the proportion of blood going in and the proportion going out is typical, your body still isn't getting enough oxygenated blood with each cardiac cycle.
Your doctor won't be able to tell whether you have HFpEF and HFrEF based on your symptoms alone.
To measure ejection fraction and diagnose the type of heart failure you have, your doctor may order tests such as:
Your doctor may prescribe diuretics to limit fluid buildup in your tissues.
They may also prescribe treatments to manage other chronic health conditions or cardiovascular risk factors you may have.
For example, they may prescribe medication to:
Your doctor may encourage you to make other lifestyle changes if necessary, including to:
Scientists are studying other treatments for HFpEF. The Food and Drug Administration (FDA) approved the drug combination sacubitril and valsartan (Entresto) in February 2021 for people with HFpEF.
Your doctor can help you learn about new treatment options as they become available or advise you if you qualify for a clinical trial testing new drugs for HFpEF.
Heart failure is a potentially life threatening condition.
A 2017 study found that all people hospitalized with heart failure survived for a median of 2.1 years. Roughly 75% of people hospitalized with HFpEF in this study passed away within 5 years.
Cardiovascular and heart failure readmission rates were higher in those with HFrEF than those with HFpEF.
Some people live for longer with HFpEF. Your outlook depends on:
Many people with HFpEF have other health conditions and cardiovascular risk factors, such as:
These conditions and risk factors raise the risk of poor health outcomes.
Getting treatment for HFpEF and other chronic conditions may help improve your quality of life and outlook. Practicing healthy habits is also important.
Roughly half of people with heart failure have HFpEF.
This condition reduces the amount of oxygen-rich blood that your heart delivers to other tissues and organs and increases the pressure in your heart.
It can cause uncomfortable symptoms and raise your chances of developing potentially life threatening complications.
It's important to get treatment for HFpEF and other chronic health conditions you may have. Your doctor may prescribe medications and other treatments. They may also encourage you to change your lifestyle to protect your heart and overall health.
No Improved Outcomes For HF Patients With Sleep Apnea Using ASV Breathing Devices
Breathing machines with adaptive servo-ventilation (ASV) did not improve survival or other clinical outcomes in patients with heart failure (HF) and reduced ejection fraction and sleep-disordered breathing, the phase III ADVENT-HF trial found.
Investigators found no difference between patients randomized to standard care plus bilevel positive airway pressure (BiPAP) device therapy with ASV and those getting standard care alone in terms of the combined primary endpoint: all-cause mortality, cardiovascular hospitalization, new-onset atrial fibrillation or flutter, and appropriate implantable cardioverter-defibrillator shock. After an average follow-up of 3.6 years, 166 primary outcome events occurred among the 356 patients in the ASV-treated group as compared with 180 events in the 375 controls (HR 0.95, 95% CI 0.77-1.18).
All-cause mortality by itself was also unchanged with ASV machines (21.3% vs 23.4%, respectively; HR 0.89, 95% CI 0.66-1.21), reported T. Douglas Bradley, MD, of the University Health Network Toronto Rehabilitation Institute, and coauthors in Lancet Respiratory Medicine.
Notably, ADVENT-HF had been prematurely terminated due to a 2021 recall of all Philips positive airway pressure devices, including the ASV devices tested in the trial, the BiPAP autoSV Advanced and BiPAP autoSV Advanced System One. The recall was attributed to identification of disintegration of motor sound-abatement material in affected devices.
In ASV's defense, Bradley's group highlighted that the ASV group in ADVENT-HF showed significant improvements in Minnesota Living with Heart Failure Questionnaire scores (average change -2.8, P=0.0009) and Epworth Sleepiness Scale (ESS) scores (-1.0, P<0.0001). These patient-reported improvements were consistent across obstructive sleep apnea (OSA) and central sleep apnea (CSA) subgroups in the open-label trial.
Additionally, study authors considered OSA and CSA eliminated with ASV.
"These novel findings argue that there might be a role for selective application of the ASV treatment strategy used herein as adjunctive therapy for patients with heart failure and reduced ejection fraction and sleep-disordered breathing, including CSA, to reduce symptom burden," the group concluded.
Unlike the SERVE-HF trial of ASV in patients with HF and reduced ejection fraction and CSA, ADVENT-HF did not show that the treatment increased mortality. Ultimately, no safety issues were identified with ASV treatment in this trial.
Atul Malhotra, MD, of the University of California San Diego in La Jolla, and colleagues noted in an accompanying editorial that many questions remain regarding treatment of sleep-disordered breathing among patients with congestive HF, including which patients should be prioritized for study and whether newer pharmacological agents should be considered to help breathing.
"In theory, positive airway pressure can decrease both preload and afterload, which could have benefits for patients with congestive heart failure," the editorialists wrote. "However, reducing preload in hypovolemic patients who have received guideline-directed medical therapy for congestive heart failure might compromise cardiac output following aggressive diuresis."
"Notably, once medical therapy for patients with congestive heart failure has been optimized, treating sleep-disordered breathing might be one of the few therapeutic targets for additional symptomatic benefit," according to Malhotra and colleagues.
ADVENT-HF was conducted at a total of 49 hospitals across nine countries. Bradley and colleagues had 1,127 patients screened and ended up with 731 participants assigned to receive standard treatment with or without added ASV therapy.
The participant population was over 85% men, and average patient age was in the early 60s. Overall, participants had only mild daytime sleepiness given a mean ESS score of 6.2. Patients were classified as 73% predominantly OSA and 27% predominantly CSA.
Predominantly OSA patients with excessive daytime sleepiness (an ESS score of greater than 10) were excluded from the study on ethical grounds.
Bradley's group acknowledged that adherence to ASV averaged just 3.8 hours per day at 5 years, with 23% of the assigned ASV group never initiating it or discontinuing it at some point during the study.
Researchers also cautioned that trial enrollment was interrupted on several occasions as a result of the negative SERVE-HF trial being published, the COVID-19 pandemic, and the Philips device recall.
Elizabeth Short is a staff writer for MedPage Today. She often covers pulmonology and allergy & immunology. Follow
Disclosures
This trial was supported by partial funding from Philips RS North America.
Bradley reported a relationship with Philips.
Malhotra reported relationships with the National Institutes of Health, LivaNova, Zoll, Jazz, Eli Lilly, and ResMed. A co-editorialist reported relationships with Bayer Pharmaceuticals, Philips Respironics, Sommetrics, Apnimed, NovaResp Technologies, and Powell Mansfield.
Primary Source
The Lancet Respiratory Medicine
Source Reference: Bradley TD, et al "Adaptive servo-ventilation for sleep-disordered breathing in patients with heart failure with reduced ejection fraction (ADVENT-HF): a multicentre, multinational, parallel-group, open-label, phase 3 randomised controlled trial" Lancet Respir Med 2023; DOI: 10.1016/S2213-2600(23)00374-0.
Secondary Source
The Lancet Respiratory Medicine
Source Reference: Patel SR, et al "Sleep apnoea in congestive heart failure: one step forwards" Lancet Respir Med 2023; DOI: 10.1016/S2213-2600(23)00377-6.
Please enable JavaScript to view the comments
What Does Ejection Fraction Have To Do With Heart Failure?
By Steven Schiff, MD, as told to Stephanie Booth
My patients' concerns about heart failure are usually, "What is my prognosis?" "What are the treatments, like medication and surgery, that are available to me?" But some people will ask me for their ejection fraction (EF) number if they've read about it, or had it discussed with them. This is especially true if they want to know if it's changing over time.
What is EF?
EF is one of many measurements of how well your heart works. It measures the active pump function of your heart when it contracts and pumps blood out of your heart and into your arteries.
Technically, EF is the percentage (fraction) of blood that is ejected from your heart as it contracts. (This is also known as the stroke volume).
Mathematically, EF is the amount of blood pumped with each beat, divided by the amount of blood in the chamber when it's filled.
Your heart has two phases for each heartbeat:
Therefore, EF is the stroke [contracted] volume/diastolic volume.
What does EF have to do with heart failure?
A low ejection fraction lets a doctor know that the active pumping phase of the heart isn't working. It's usually tied to some, but not all, types of heart failure.
Heart failure with a low EF is called "systolic" heart failure.
How is EF measured?
EF is usually measured, with an echocardiogram or cardiac ultrasound. It can also be measured during a heart angiogram and catheterization. That's when catheters (tubes) are put inside of you through an artery, into your heart chambers.
Other measurement techniques include:
All of these techniques are estimates, and can show slightly different results in the same person.
What do EF numbers mean?
Normal EF is in the range of 55% to 70%. As the percentage falls, it tells the doctor that the heart failure is getting worse. In general, if the EF falls below 30%, it's relatively severe. A reading of 20% or below is very severe heart failure.
It's important to know that there's not always a perfect correlation between symptoms and the EF. In addition, an EF above 75% is considered too high, and can be a problem as well.
How can your EF help manage your heart health?
Your EF can be a way of assessing the status and progression of heart failure over time, as well as a way to track the benefits of various heart failure treatments.
For instance, you may be told your EF, then start on medication or go for surgery, and may want to know: "Did my EF go up or down?" We can track serial measurements of EF (usually by echocardiogram) to see if your treatment is helping.
How can you have normal EF and heart failure?
Heart failure with a normal EF is happening more and more often. It's generally related to the filling phase of the heart's cycle of filling and emptying. It is called "diastolic heart failure."
Normal hearts are very compliant. This means that they fill easily, at relatively low pressures. Sometimes, even though the heart contracts normally (normal EF), it might need higher pressure to fill for each beat.
If so, you can have symptoms of heart failure even though your heart contracts normally, with a normal EF. You could have fluid accumulation and overload. We see this most frequently in people with untreated high blood pressure.
Should you find out your EF?
Most people without cardiac issues don't need to know their EF.
If you're simply worried about this, ask your doctor if you should be concerned. A simple echocardiogram will provide a good estimate.
The most important thing to know, if you have been told of heart failure, is what the underlying cause is. That will affect your prognosis, treatment, testing and follow-up.
Among the most common causes [of heart failure] are:
Once you've been given a heart failure diagnosis, you should be seen by a cardiologist for a careful review of your underlying causes, the status of your heart failure, your current treatment, follow up, and prognosis.
Comments
Post a Comment