Retrospective Observational Analysis of a Cohort With Heart Failure With Preserved Ejection Fraction
Condition: Heart Failure With Preserved Ejection Fraction
MeSH terms: Heart Failure
Study type: Observational

Summary: 
      Heart failure with preserved ejection fraction (HFpEF) is a complex condition with various
      causes that is not yet fully understood. Most significantly there is no single method of
      diagnosing or treating the condition. Recently a novel non-invasive diagnostic criterion to
      predict the likelihood of HFpEF was proposed called H2FPEF. The main limitation of this study
      was the use of a single centre population from the Mayo clinic in Rochester, US. Another
      limitation is that the H2FPEF diagnostic criterion consists of common and often co-existing
      conditions which could as a result overestimate HFpEF probability. The aim of the
      investigators is to retrospectively test the H2FPEF criteria on the population at Queen
      Alexandra Hospital (QAH) in Portsmouth, which is of a lower socio-economic status and greater
      ethnic diversity. Implications of the proposed project if H2FPEF is proved to be
      generalizable to the study population is that it can be used within the Trust and rolled out
      to others. This would allow diagnosis to be made quicker and more cost effectively using
      echocardiography and without the need for invasive cardiac catheterisation. On the other hand
      if H2FPEF is found not to be applicable to the population then further research would be
      required to find the ideal diagnostic tool.
    

Detailed description: 
      HFpEF was previously characterised as 'diastolic dysfunction' but this terminology was
      changed as it was found that diastolic dysfunction was also seen in patients with 'systolic
      dysfunction'. Myocardial stiffness which leads to increased filling pressures is a common
      pathophysiologic attribute of HFpEF despite its multifactorial aetiology. Other common
      conditions associated with HFpEF include: atrial fibrillation (AF), chronotropic
      incompetence, pulmonary hypertension, right ventricular dysfunction and endothelial
      dysfunction; with common non-specific risk factors such as: age, gender, hypertension,
      obesity, diabetes, metabolic syndrome and renal failure. This complex heterogeneity of HFpEF
      which is not yet fully understood highlights the difficulty that clinicians have in being
      able to diagnose the condition.

      Diagnosis of HFpEF is difficult and as of yet there is no test to confirm diagnosis, with
      current guidelines saying initial diagnosis should include the presence of typical signs and
      symptoms, an elevated B-type natriuretic peptide (BNP) (>35 pg/mL and/or N-Terminal
      pro-B-type Natriuretic Peptide [NT-proBNP] >125 pg/mL) and ejection fraction ≥50%.
      Echocardiography is the preferred method of assessing for HFpEF due to it being widely
      available, non-invasive, and able to provide immediate results. Recent studies comparing the
      use of echocardiography against 'gold standard' invasive cardiac catheterisation to assess
      cardiac filling pressures found echocardiography to be just as accurate and reliable.
      Implications of this research would be that patients could be assessed as outpatients by
      focus echocardiography rather than invasively in the cardiac catheterisation lab, which would
      improve patient experience, enhance patient outcomes and prove cost-effective for trusts.

      In response a recently proposed non-invasive diagnostic criteria called H2FPEF which assesses
      patients based on body mass index (BMI), the number of hypertensive medications they take,
      presence of AF, pulmonary pressure, age and filling pressure. The advantage of the H2FPEF
      score is that it uses only non-invasive echocardiography data alongside routine clinical data
      making it easy to derive. However one key limitation of their study is the population they
      used was all from the Mayo clinic and so the generalisability of their results has not been
      tested for other populations, such as those of lower socioeconomic status like in Portsmouth.
      A further limitation is the parameters chosen to create H2FPEF are all relatively common
      morbidities and usually co-exist, making it likely that it will over diagnose HFpEF.
    

Intervention name(s): No intervention, observational only
Intervention type(s): Other
Intervention description(s): No intervention, observational only
Observational model: Case-Only
Time perspective: Retrospective
Sampling method: Non-Probability Sample
Study population: 
        All participants will be patients who have attended heart failure clinics at QAH between
        01/01/2016 - 31/12/2016. Eligibility will be met by the inclusion and exclusion criteria.