Peter L. Salgo, MD: Why don’t we talk about, if you will, the classic patients. Putting aside those patients with normal ejection fractions, let’s discuss the patients who have heart failure with reduced ejection fraction. Not being a cardiologist, I wasn’t aware that you guys calls this “HFrEF.”
Scott Solomon, MD: We do.
Peter L. Salgo, MD: What proportion of heart failure with reduced ejection fraction is that of the entire heart failure population?
Scott Solomon, MD: It’s about 50%.
Peter L. Salgo, MD: It’s a lot.
Scott Solomon, MD: It depends on which survey you look at, but overall, we consider heart failure with reduced ejection fraction to be an ejection fraction that is less than or equal to 40%.
Peter L. Salgo, MD: Forty percent is your what?
Scott Solomon, MD: Forty percent is our cutoff. Above that, we call it heart failure with preserved ejection fraction (HFpEF). Now, the Europeans have made a new category. They’re calling it heart failure with mid-range ejection fraction. But we’ve traditionally called anything 40% and below, HFrEF, and anything above 40%, HFpEF. The main distinction though, because these are arbitrary cutoffs, is that there is no evidence-based therapy that has yet been proven to work in patients with heart failure with preserved ejection fraction, whereas we have a whole armamentarium of therapies in patients with heart failure with reduced ejection fraction.
Peter L. Salgo, MD: So, it’s going to be fruitful to drill down on these HFrEF patients?
Scott Solomon, MD: Yes.
Peter L. Salgo, MD: Reduced-ejection fraction patients. So, let’s establish, again, right at the outset, who are we talking about? What are the characteristic patients with HFrEF? What do they look like?
Orly Vardeny, PharmD, MS: They’re patients who have multiple comorbid conditions. Up to two-thirds of them will have coronary heart disease. A lot of them, up to 40%, may have diabetes or atrial fibrillation. Many of them have longstanding hypertension, so they have risk factors and concomitant diseases that go along with heart failure and may increase the risk of getting heart failure.
Peter L. Salgo, MD: These are kind of the classic patients, right? The patients with peripheral vascular disease or other evidence for vascular injury going forward. These are the ones you looked at on the Netter diagram when you were in medical school.
Scott Solomon, MD: The important thing to remember about HFrEF is that these are patients who have an abnormality of cardiac contraction for a whole host of reasons. Some of them have it because they had heart attacks. Some of them have longstanding hypertension. Some of them have genetic cardiomyopathies. Some of them have left bundle branch block, which leads to an electrical dyssynchrony that can make their heart worse. But the end of the day, their heart doesn’t pump as well as it should, and that’s really the primary problem. And that causes a lot of other things to happen, like a neurohormonal cascade that is secondary to that. But the primary problem is the lack of contractile function.
Akshay Desai, MD: In that way, heart failure with reduced ejection fraction is kind of the final common pathway for a lot of different illnesses. Over time, experts have made this point, that the lifetime risk of developing heart failure is about 20% for most people, independent of the age at which you start. And it’s largely because if you’re lucky enough to survive your heart attack, then down the road, you might develop heart failure.
Peter L. Salgo, MD: I didn’t miss that in the middle of your sentence: “If you’re lucky enough to survive your heart attack.” So, post myocardial infarction (MI) is one category of folks who have a problem with this. You don’t need to have a MI to have this.
Akshay Desai, MD: No. Scott listed a number of different things that are there. Hypertension is a big driver. And, as Orly pointed out, control of blood pressure if a critical feature of trying to prevent heart failure development.
Peter L. Salgo, MD: What do these folks look like when they come into your office? In medical school, I was taught that with heart failure, you squish you when you walk and you pant. You don’t breathe very well. What do you look like? What do these HFrEF folks look like?
Scott Solomon, MD: If you think about what is heart failure, I like a definition that says that heart failure is the inability of the heart to provide enough cardiac output to the body or to do so only at the expense of elevated filling pressures. Now, what does that mean? Elevated filling pressures mean that you have congestion. If the left side of the heart can’t function as well as it should, that blood is going to back up into the lungs and then it’s going to keep backing up into the periphery as well. So, congestion is one of the primary things that we see in these patients. They have shortness of breath, and they can even have pulmonary edema. They can have right-sided edema, including swollen ankles, early satiety, and so forth. Their neck veins are elevated. In addition of their not providing enough cardiac output, they can be tired. They may not be able to do the things that they want to do. And you have to be able to ask the patients, “What can you really do?” If you ask, “How do you feel?” they may say that they feel fine. But if you say, “Can you make your bed?” “No, I can’t do that without feeling short of breath.”