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Improved Understanding of Heart Failure


A key opinion leader discusses how the medical understanding of heart failure has improved over the years and how it has helped management of disease.

John McMurray, MBChB: We’ve learned a lot about heart failure in the last 2 decades. Even just in the past 5 or 6 years, we’ve made great breakthroughs. Our major advance has been understanding how to treat 1 of 2 major heart failure phenotypes or subgroups. Those are patients who got heart failure with a reduced ejection fraction where the problem is with the contracting and the emptying of the left ventricle of the heart. We now have many pharmacological drugs and treatment devices for that type of heart failure.

What we have not advanced much with is the management of the other major phenotype, which is heart failure with preserved ejection fraction, where the problem is 1 of impaired relaxation and filling of the left ventricle. A pump has to both fill and empty to work properly. We haven’t had any major breakthroughs there, though there has been a conceptual breakthrough in the sense that we realize that heart failure with preserved ejection fraction is probably at least 2 different subtypes of heart failure.

There are individuals who have completely normal ejection fraction where the emptying—the pumping—of the heart is normal, and there are people who have pumping or an ejection fraction that is not normal. But it’s not low, so it’s not in that former heart failure group with reduced ejection fraction. For people who have an ejection fraction below normal but not very low, we are beginning to realize that those patients may constitute a distinct phenotype.

Those individuals may benefit from some of the treatments that we know work in people with a reduced ejection fraction. Maybe we will soon begin to see an expansion of the use some of the treatments we have for heart failure with reduced ejection fraction to a proportion of patients with heart failure with preserved ejection fraction. Some people call those individual patients with heart failure in midrange a mildly reduced ejection fraction.

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