“Epidemiological studies indicate that 50% of patients with HF have HF with preserved ejection fraction (HFpEF), and the prevalence is increasing,” explains Christi Deaton, PhD, RN, FAHA, FESC, FAAN. “Yet, the condition remains less well understood, underdiagnosed, and variably managed. HFpEF typically occurs in older patients with multimorbidity, a high prevalence of obesity, and metabolic syndrome, although there is heterogeneity. Most research on HFpEF, however, includes patients that may not reflect the prevailing phenotype of patients, as they are younger with fewer and/or less severe comorbidities.”
For a study published in BJGP Open, Dr. Deaton and colleagues sought to understand what was happening in practice from the perspective of both patients and healthcare providers across different healthcare settings, to characterize patients in primary care with HFpEF, identify problems that could be addressed, and consider solutions and interventions that could be tested. A screening algorithm and review were used to find patients in practice HF registries without a record of reduced EF. Baseline assessment included cardiac, mental and physical function, clinical characteristics, and patient-reported outcomes. Confirmation of HFpEF was clinically adjudicated by a cardiologist.
Greater Awareness & Understanding Needed
The study team found a significant need for greater awareness and understanding of HFpEF across healthcare settings, particularly in primary care, Dr. Deaton notes. “Patients with HFpEF are complex, as they have multiple morbidities, and frequent geriatric syndromes such as sarcopenia, frailty, and impairments in physical function. We need to manage their HF, but they also need holistic management with focus on multimorbidity and geriatric syndromes. In addition, better collaboration and communication are needed across healthcare sectors, especially between specialist services and primary care, as well as specialists and their colleagues in gerontology. Finally, diagnosis remains challenging, especially for older patients. Therefore, we need better diagnostic tools and systems.” The researchers found that patients with HFpEF were more symptomatic than the non-HFpEF group, Dr. Deaton notes. “In addition, patients overall had low self-care behavior scores,” she says. “For example, few patients weighed themselves daily or knew to report short-term weight gain. Outside of specialist services, many patients are not taught or supported in self-management, and this is an important component of care for those with HF. However, we were surprised that despite symptoms and functional impairment, patients reported fairly good QOL (Table).”
Other studies, Dr. Deaton points out, have shown that older patients tend to report higher QOL than younger ones and speculate that this is due to different expectations at different ages. “Some patients reported that they had difficulty in differentiating symptoms of HF, compared with the effects of other conditions,” she says. “For the patient, illness and symptoms are integrated, and highlights the importance of managing the patient and not the condition.”
Better Access to Cardiology Services Is Key
In this study, Dr. Deaton and colleagues have provided a snapshot of the characteristics of patients with HFpEF recruited from primary care, highlighted numerous issues particular to this group, and documented the challenges of diagnosing and managing patients. “Cardiologists have a role to play in educating and supporting primary care and community services,” she says. “Going forward, we need to determine how cardiologists and heart failure specialist nurses can provide better access for patients with HFpEF (without becoming overwhelmed), ensure robust diagnostic procedures, and work collaboratively to provide evidence-based treatment.”
In the future, the study team would like to see clinicians utilize efficient and effective pathways that lead to earlier diagnosis and appropriate management, including integrated management of comorbidities, access to cardiac rehabilitation, and support for self-management. “More research should be done around new pharmacological therapies, such as sodium glucose co-transporter-2, or SGLT2, inhibitors,” she says. “Researchers should also continue to focus on understanding different phenotypes in HFpEF so that we can target treatment for different groups.”