JACC: HEART FAILURE VOL. 2, NO. 5, 2014
Letters to the Editor
OCTOBER 2014:538–44
Atherosclerosis) (5) has shown that EF “normally”
we are united in our efforts to better understand,
rises with age and is higher in women than men in
prevent, and treat this syndrome.
the general population (Figure 1). The key issue is that EF is a fraction, which will increase as the heart
*Carolyn S.P. Lam, MBBS
remodels and the LV end-diastolic volume (denomi-
*National University Health System
nator) shrinks out of proportion to the stroke volume
Tower Block Level 9
(numerator). This prompts the question, what is the
1E Kent Ridge Road
normal EF in an elderly female patient who has HF? If
Singapore 119228
“normal” is a higher EF in these patients, then by
E-mail: [email protected]
using an age- and sex-neutral cutoff of 50% to define
http://dx.doi.org/10.1016/j.jchf.2014.04.013
HFNEF, we are effectively selecting for elderly
Please note: Dr Lam is supported by a Clinician Scientist Award from the National Medical Research Council of Singapore; has received research grants from Boston Scientific, Medtronic, and Vifor Pharma; and has received consultancy fees from Bayer Healthcare and Novartis.
women who actually have “relatively abnormal” EF for their age and sex. By extrapolation, this concept may apply to all subjects with smaller heart sizes (smaller LV end-diastolic volumes)—not just women (versus men) or those with concentrically remodeled ventricles (elderly, hypertensive), but also subjects of smaller body size in general. One may stop here and argue that we should not be looking at EF in the first place (1). However, the most significant counterargument to this is that clinical trials using EF to stratify HF have revealed 2 phenotypes that respond differently to the same therapy: renin-angiotensin-aldosterone system blockade improves survival in HFrEF, but not in HFNEF. Any classification that can guide treatment would be
REFERENCES 1. Sanderson JE. HFNEF, HFpEF, HF-PEF, or DHF: What is in an acronym? J Am Coll Cardiol HF 2014;2:93–4. 2. Topol EJ, Traill TA, Fortuin NJ. Hypertensive hypertrophic cardiomyopathy of the elderly. N Engl J Med 1985;312:277–83. 3. Wang TJ, Evans JC, Benjamin EJ, Levy D, LeRoy EC, Vasan RS. Natural history of asymptomatic left ventricular systolic dysfunction in the community. Circulation 2003;108:977–82. 4. He KL, Burkhoff D, Leng WX, et al. Comparison of ventricular structure and function in Chinese patients with heart failure and ejection fractions >55% versus 40% to 55% versus
Letters to the Editor
OCTOBER 2014:538–44
Atherosclerosis) (5) has shown that EF “normally”
we are united in our efforts to better understand,
rises with age and is higher in women than men in
prevent, and treat this syndrome.
the general population (Figure 1). The key issue is that EF is a fraction, which will increase as the heart
*Carolyn S.P. Lam, MBBS
remodels and the LV end-diastolic volume (denomi-
*National University Health System
nator) shrinks out of proportion to the stroke volume
Tower Block Level 9
(numerator). This prompts the question, what is the
1E Kent Ridge Road
normal EF in an elderly female patient who has HF? If
Singapore 119228
“normal” is a higher EF in these patients, then by
E-mail: [email protected]
using an age- and sex-neutral cutoff of 50% to define
http://dx.doi.org/10.1016/j.jchf.2014.04.013
HFNEF, we are effectively selecting for elderly
Please note: Dr Lam is supported by a Clinician Scientist Award from the National Medical Research Council of Singapore; has received research grants from Boston Scientific, Medtronic, and Vifor Pharma; and has received consultancy fees from Bayer Healthcare and Novartis.
women who actually have “relatively abnormal” EF for their age and sex. By extrapolation, this concept may apply to all subjects with smaller heart sizes (smaller LV end-diastolic volumes)—not just women (versus men) or those with concentrically remodeled ventricles (elderly, hypertensive), but also subjects of smaller body size in general. One may stop here and argue that we should not be looking at EF in the first place (1). However, the most significant counterargument to this is that clinical trials using EF to stratify HF have revealed 2 phenotypes that respond differently to the same therapy: renin-angiotensin-aldosterone system blockade improves survival in HFrEF, but not in HFNEF. Any classification that can guide treatment would be
REFERENCES 1. Sanderson JE. HFNEF, HFpEF, HF-PEF, or DHF: What is in an acronym? J Am Coll Cardiol HF 2014;2:93–4. 2. Topol EJ, Traill TA, Fortuin NJ. Hypertensive hypertrophic cardiomyopathy of the elderly. N Engl J Med 1985;312:277–83. 3. Wang TJ, Evans JC, Benjamin EJ, Levy D, LeRoy EC, Vasan RS. Natural history of asymptomatic left ventricular systolic dysfunction in the community. Circulation 2003;108:977–82. 4. He KL, Burkhoff D, Leng WX, et al. Comparison of ventricular structure and function in Chinese patients with heart failure and ejection fractions >55% versus 40% to 55% versus
