Category: Cardiovascular Disease (CVD)

A Practical Score to Guide Diagnosis of HFpEF

Approximately 50% of heart failure patients have a preserved ejection fraction (HFpEF), a condition which is particularly complex to both diagnose and treat. Compared to HF patients with reduced ejection fraction (HFrEF), HFpEF patients are often older, female, and present with increased metabolic comorbidities such as obesity, hypertension, and type 2 diabetes mellitus. These metabolic comorbidities are associated with an increased risk of developing HFpEF: leading to a concerning increase in metabolic syndrome. Indeed, the prevalence of HFpEF has not only spiked in the last few decades, but also coincided with the rise of metabolic syndrome. Moreover, current pharmacological therapies that have demonstrated success in reducing morbidity and mortality in HFrEF patients are ineffective in patients with HFpEF.

Diagnosing HFpEF is further challenging because symptoms are often indistinguishable with HFrEF. This is especially true during the early stages of HFpEF, when a normal ejection fraction and lack of additional symptoms can contribute to an undetected condition. One of the few present symptoms in early stages is exercise dyspnea, due to fluid accumulation in the lungs: common in patients with HF. Yet properly evaluating reduced exercise capacity is challenging in older and obese patients, most of whom constitute the HFpEF patient population. Diagnosis of HFpEF becomes more complex when considering the lack of consensus regarding the definition of EF cut-off criteria, coupled with the fact that such diagnosis must be based upon the exclusion of other common symptoms associated with heart failure.

A particular challenge concerns the diagnosis of HFpEF in patients that present with unexplained exertional dyspnea; in this setting, right-sided heart catherization followed by invasive exercise testing may be required to distinguish between cardiac and non-cardiac causes, and to confirm a diagnosis of HFpEF. However, many clinicians agree that the invasive nature of these procedures does not make them well-suited for routine clinical practice. Dr. Yogesh Reddy and colleagues recently developed and validated a non-invasive score to help clinicians determine the likelihood of HFpEF in patients presenting with unexplained exertional dyspnea. The score, termed H2FPEF, is based on the presence or absence of several measurable risk factors: BMI >30 kg/m2, hypertension defined as currently on two or more antihypertensive medications, paroxysmal or persistent atrial fibrillation, pulmonary hypertension defined as pulmonary artery systolic pressure > 35 mmHg, age >60 years, higher filling pressures defined as E/e’ >9 and ranges from 0-9 points (a higher score likely indicates a greater probability that a patient has HFpEF). Indeed, when validated in a separate test cohort, an increased H2FPEF score was predictive of HFpEF probability: for example, a H2FPEF score of >5 helped to predict HFpEF with 90% probability. This score could prove useful in establishing the probability of HFpEF, and rule out this disease in patients with low scores (e.g. 0 or 1). Furthermore, the score could help guide clinicians in confirming a diagnosis in patients with higher (6-9) scores.

Reddy, Yogesh NV, et al. “A Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure with Preserved Ejection Fraction.” Circulation (2018): CIRCULATIONAHA-118.

The Risk of Heart Disease with Painkillers

A large-scale study conducted in 2017 originally indicated that common painkillers like ibuprofen and naproxen are considered risky for people who have had heart attacks; additional research has demonstrated that the risk can begin within the first week of usage.

The initial study involved NSAIDs: non-steroidal anti-inflammatory drugs, including ibuprofen—generically known under its brand names Advil and/or Motrin. Researchers at McGill University pooled extensive studies and clinical research on NSAIDs and heart attacks, using a data pool of over 446,000 people who used the drugs, including 385,000 participants who did not have heart attacks.

The report, published in the British Medical Journal, stated that current use of a NSAID is “associated with a significantly increased risk of acute myocardial infarction,” the medical terminology for a heart attack. Moreover, the risk began within a week of usage. The data demonstrated that those who used NSAIDs were more likely to have a repeat heart attack, or die within the next 5 years. In the first year post-heart attack, 20 percent of NSAID users died, compared to approximately 12 percent of non-users. The death rate of NSAID users remained about double than that of non-users in the next few years.

A number of studies have consistently revealed similar patterns concerning NSAIDs and heart disease, coupled with biological reasons that NSAIDs could be risky for people with heart disease. Evidence suggests that the drugs may impact and affect blood clotting, blood vessel function, and blood pressure. Because NSAIDs are available over the counter, many patients and consumers believe that there is no inherent danger involved.

The U.S. Food and Drug Administration has already added ‘black box warnings’ to NSAIDs, warning people with higher risks for heart disease and blood pressure to avoid using them without the recommendation of a physician. Dr. Gordan Tomaselli, chief of cardiology at Johns Hopkins University, advises: “if you’ve ever had a heart attack, you should use NSAIDs with caution.”

More recent research has indicated that for patients with osteoarthritis, NSAIDs increase the risk for cardiovascular disease to more than twice the rate of the general population. “There’s no cure for people with osteoarthritis, and you have to treat the pain. But when you treat it with NSAIDs, you increase cardiovascular risk,” said Aslam Anis, PhD, from the University of British Columbia in Vancouver, Canada.