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• Re:It is important to distinguish between HFrEF and HFpEF when interpreting these data
  Brian J Lipworth
  Published on: 26 August 2016
• It is important to distinguish between HFrEF and HFpEF when interpreting these data
  Colin Cunnington
  Published on: 14 July 2016

• Published on: 26 August 2016

  Re:It is important to distinguish between HFrEF and HFpEF when interpreting these data

  • Brian J Lipworth, Pulmonologist
  • Other Contributors:
    • David Price ,Graham Devereux,Jessica Martin

  We would like to thank Dr Cunnington for his interest in our study and raising some potentially interesting points . We do not have a breakdown of patients with heart failure ( HF) who had either preserved (HFpEF) or reduced ejection fraction (HFrEF) . Since beta-blockers only have a licensed indication for HFrEF on the basis of an echocardiogram , we do not believe that this is likely to be a relevant factor withi...

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  We would like to thank Dr Cunnington for his interest in our study and raising some potentially interesting points . We do not have a breakdown of patients with heart failure ( HF) who had either preserved (HFpEF) or reduced ejection fraction (HFrEF) . Since beta-blockers only have a licensed indication for HFrEF on the basis of an echocardiogram , we do not believe that this is likely to be a relevant factor within our dataset . The relative prevalence of hypertension within our cohort was 13.3% verses 11.6% ,and for diabetes was 47.4% verses 41.9% respectively for HF alone verses HF with COPD . Hence the assertion made regarding a higher putative comorbidity is not supported by the data presented here . Consequently prescribing of ACEI/ARB in HF with COPD was not confounded by comorbidity due to treatment for either diabetes or hypertension . The higher use of ACEI/ARB without beta-blocker in HF with COPD compared to HF alone is more likely to reflect a reticence of physicians to prescribe add on therapy with beta-blockers in the presence of airflow obstruction due to fears of bronchoconstriction . As such we remain confident in the strength of our conclusions regarding underuse of beta-blockers in HF with COPD .

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 14 July 2016

  It is important to distinguish between HFrEF and HFpEF when interpreting these data

  • Colin Cunnington, Consultant Cardiologist

  In this interesting article, Lipworth and colleagues report that beta -blockers are underused in patients with heart failure (HF) and COPD, compared to those with HF alone. However, they do not quote the proportion of "HF" patients within their dataset who had HF with reduced ejection fraction (HFrEF; left ventricular ejection fraction (LVEF) <40%) and HF with preserved ejection fraction (HFpEF; LVEF >50%). This d...

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  In this interesting article, Lipworth and colleagues report that beta -blockers are underused in patients with heart failure (HF) and COPD, compared to those with HF alone. However, they do not quote the proportion of "HF" patients within their dataset who had HF with reduced ejection fraction (HFrEF; left ventricular ejection fraction (LVEF) <40%) and HF with preserved ejection fraction (HFpEF; LVEF >50%). This distinction is important, as beta-blockers are only recommended in HF guidelines for patients with HFrEF (1), owing to a lack of trial data to support their efficacy in patients with HFpEF.

  Furthermore, patients with HFpEF tend to have a higher prevalence of co-morbidities compared to patients with HFrEF, including COPD, hypertension and diabetes (2). Thus, it is possible that "HF and COPD" patients in this dataset may have a higher proportion of HFpEF to HFrEF, in comparison to patients with "HF alone", and the rates of ACE/ARB prescribing may be increased in this group owing to treatment of hypertension and diabetes rather than HF. These considerations may therefore confound the strength of the authors' conclusions regarding underuse of beta-blockers in patients with HF and COPD.

  References

  1. Ponikowski P, Voors AA, Anker SD et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016; DOI: 10.1093/eurheartj/ehw128.

  2. Ather S, Chan W, Bozkurt B et al. Impact of non-cardiac comorbidities on morbidity and mortality in a predominantly male population with heart failure and preserved versus reduced ejection fraction. J Am Coll Cardiol 2012;59:998-1005.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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