Tweet

Sriram Sunil Kumar

Jun 26 • 18 tweets • 12 min read

A patient with heart failure that you have been following for the last five years no longer has a low EF. What changed ? What medications do you add/stop ?

A #MedTwitter #Tweetorial on HFimpEF (HF with improved EF).

First let’s talk the nuances of calculating EF. 🧮

(1/14)

EF = (EDV-ESV)/EDV or the percentage of EDV ejected by the LV. This volumetric analysis is performed by echocardiography. However in some cardiac diseases, the EF calculated can be falsely ⬆️/⬇️.
This can happen in which of the following conditions ?
2/n

That’s right ! Both MR and AR can produce a wrong EF reading. The calculation fails to account for the portion of blood that is ejected into the LA in MR (⬆️EF) and the regurgitant back flow from Aorta in AR (⬇️EF).
Cardiac MRI can more accurately predict EF in these patients.

Even though descriptions of heart failure have existed for centuries, our understanding of the disease has drastically changed over the past few decades. Romans used extracts of the foxglove plant to treat heart disease. Later, digoxin was derived from its leaves. 4/n

Hippocrates was the first to associate the symptomatology with the heart. In his books, he describes that “when the ear is held to the chest, and one listens for some time, it may be heard to seethe inside like the boiling of vinegar”. What PE finding is he referring to ?
5/n

He was describing rales heard in pulmonary edema. Listen here- shorturl.at/npADZ.
Once William Harvey described circulation in 1628, the stage was set for a better understanding of heart failure. The 20th century was clinical and led to our current perspectives.
6/n

Initially heart failure was synonymous with LV dysfunction. In 1966, presbycardia/senile heart disease was described as a rare condition in older patients where features of HF developed due to decreased elasticity of the heart.
7/n

With the advent of echo, this was later described as HF with preserved EF (HFpEF). We also learnt that EF which was initially thought to be static, is a dynamic quantity that can ⬆️/⬇️ over time. In a study of natural history of HF, EF was calculated at 5358 visits. ⬇️
8/n

Patients with HFrEF seemingly improved their EF to normal levels. AHA/ACC in 2013 (revised 2022) thus formed a new system of classification of HF beyond HFrEF and HFpEF. HF with improved EF(HFimpEF) is HFrEF with documented EF <= 40% that subsequently increases to >40%.
9/n

The treatment of HFrEF hinges on guideline directed medical therapy or GDMT. GDMT = clinical eval + dx testing + medications + required procedures. Which medication forms the crux of GDMT ?
10/n

It’s all of them- they are the four pillars of GDMT. These drugs not only prevent further remodelling and improve mortality but also support reverse remodelling of the heart and thus improve EF. This may move the patient into the HFimpEF category.
11/n

https://twitter.com/w_jyg/status/1520984471981334528

It is therefore imperative to know that HFimpEF patients are usually those that have benefitted from GDMT in HFrEF. However, even asymptomatic HFimpEF patients are not fully recovered/cured and many relapse if GDMT is withdrawn.

Parasternal views showing HFimpEF with GDMT. ⬇️

https://twitter.com/w_jyg/status/1520984471981334528

Take-home tweet:

HFimpEF is essentially HFrEF(documented <=40%) that has now improved.
Treat as HFpEF ? Nope.
Continue and optimize GDMT as required.

13/14

@SinaiBmoreIMRes

Full disclosure: I did not know about HFimpEF till a few months back during my rotation at @SinaiBmoreIMRes @rav7ks.
All suggestions and corrections welcome.

14/14