The article by Caruana et al. describing alternative diagnoses for
heart failure in primary care patients with normal left ventricular
ejection fractions (LVEFs) raises important questions.1 While we share
their uncertainty of what to do with these patients and the apparent
ubiquity of "diastolic dysfunction" on echocardiograms in the elderly, we
are unconvinced that the alternative diagnoses represent actual causes for
patients' symptoms or primary care physician misdiagnoses. We believe
their study emphasizes our poor understanding of the complex nature of
heart failure in the elderly and the lack of a scientific basis for
understanding cardiac decompensation separate from systolic dysfunction.
The authors find solace in the high prevalence of pulmonary disease,
obesity and myocardial ischemia and propose these as alternative diagnoses
for patients with heart failure symptoms. We are troubled that they have
invoked these as potential etiologies when they may simply be co-
morbidities that primary care physicians already new existed. We suspect
that this is not the case.
In our study of 338 patients with a primary care "clinical" diagnosis
of heart failure, over half of the patients studied by echocardiogram had
a normal LVEF. 2 Of all the patients studied, 65% had associated cardiac
comorbidities, while 35% had pulmonary co-morbidities. The prevalence of
these comorbidities was identical among patients with documented systolic
dysfunction and those with a normal LVEF. However, systolic heart failure
patients were more likely to have suffered a myocardial infarction.
Although obesity and BMI were not measured in our study, it was a
prevalent condition in this population, not unknown to the primary care
Caruana and colleagues do not examine patients with systolic heart
failure to assess their susceptibility to the alternative diagnoses they
propose for symptoms. As for treatment of the alternative diagnoses, we
suspect that the scientific evidence for treating and clinically improving
elderly patients with obesity and pulmonary disease is no further along
than research on diastolic dysfunction.
The paper by Caruana et al is a clarion call for improving the
scientific basis of heart failure with normal LVEF. While diastolic
dysfunction may be a murky and difficult clinical diagnosis to accept,
these alternative diagnoses offer little hope to the primary care
physician attempting optimal management. We await larger epidemiological
studies of elderly patients with heart failure symptoms and normal LVEFs.
Perhaps older physicians had a better understanding of this syndrome when
they named it "presbycardia."3
1. Caruana L, Petrie M, Davie A, McMurray J. Do patients with
suspected heart failure and preserved left ventricular systolic function
suffer from "diastolic heart failure" or from misdiagnosis? A prospective
descriptive study. BMJ. 2000;321:215-219.
2. James P, Cowan T, Graham R, Jaén C, Majeroni B, Schwartz J. Heart
Failure in Primary Care: Measuring the Quality of Care. J Fam Prac.
3. Dock W. Presbycardia or Aging of the Myocardium. N Y State J Med.
Competing interests: No competing interests