Letters Heart failure

Heart failure is in need of a diagnosis

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b961 (Published 09 March 2009) Cite this as: BMJ 2009;338:b961
  1. Guy Lloyd, consultant cardiologist1
  1. 1East Sussex NHS Trust, Eastbourne District General Hospital, Eastbourne, East Sussex BN21 2UD
  1. guy.lloyd{at}btinternet.com

    How attractive to have a syndrome where the clinical findings are “right” and the tests are “wrong.” In heart failure with normal ejection fraction (HEFNEF), the presentation is consistent with heart failure but echocardiography does not fully agree. Sanderson and Yip advance that this results from predictable pathology with a well understood prognosis.1

    But the loss of rotational and longitudinal architecture occurs in other diseases such as hypertrophic cardiomyopathy long before symptoms develop. In “conventional” heart failure, the heart is enlarged and contractility is reduced, resulting in increasing breathlessness and fluid overload. Prognosis is predictably modified by drug treatment, and, although the causes are legion, the final result, a big baggy heart, is consistent.

    In patients with HEFNEF the results of randomised trials have been negative or marginal,2 3 4 suggesting that the normal relation between preload, afterload, contractility, and prognosis does not apply—an unlikely finding in a disease continuum. Furthermore, the mortality and morbidity in the HEFNEF groups is dramatically better than in those with depressed ejection fraction, reflecting stricter criteria for diagnosis than in epidemiological cohorts. Epidemiology suggests that half of all cases of heart failure are HEFNEF, and the prognosis is bad.5

    This is an intellectual fork in the road. The choice is either to accept that the echocardiography results are misleading and accept a diagnosis of HEFNEF or to examine for other potential causes. The clinical findings (and often the raised B type natriuretic peptide value) are far from unique, occurring in many cardiac, pulmonary, renal, and venous diseases, none of which is benign. Cases of “diastolic heart failure,” or HEFNEF, do exist, but they are comparatively rare. To jump to this diagnosis without meticulous investigation, including detailed echocardiography (not available in many areas), risks treating the wrong disease. I propose a new term: heart failure not adequately diagnosed (HEFNAD).


    Cite this as: BMJ 2009;338:b961


    • Competing interests: None declared.


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