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- John E. Sanderson, MA, MD∗ ( )()
- ↵∗Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong
Dr. Lam makes many sensible and reasonable comments in response to my viewpoint, and it appears we are in agreement on most aspects. Of course, one can quibble about the definition of what is a truly “normal” ejection fraction (above 45%, 50%, or 55%), but it is curious that this objection is never raised when discussing the definition of heart failure with a “reduced” ejection fraction, although it can have equally important implications (1). Presumably, if one can define a reduced ejection fraction, then everything above that is fairly acceptable, and the generally recognized cutoff would appear to be 50%. However, “preserved” is definitely not the correct word to use because it is clear that in the condition some call “HFNEF,” the ejection fraction is not unchanging, but rather gradually falls; and whatever else is debatable, the definition of the word preserved is not arguable: it is generally accepted to mean something that is unchanged or “maintain (something) in its original or existing state” (OED) (2). It may appear to be nitpicking, but precision in the use of words is important, especially in science as well as politics (as George Orwell said if “thought corrupts language, language can also corrupt thought” ).
It seems obvious now that the current classification of HF has broken down and is rapidly becoming meaningless. The best way forward would be to drop all references to the ejection fraction because basing the diagnosis of heart failure on the left ventricular (LV) ejection fraction alone has resulted in excluding a large proportion of heart failure patients from treatment trials. It would be best to make a clinical diagnosis of heart failure, determine the cause (hypertensive, ischemic, ageing, or multifactorial, etc.) and the pathophysiological mechanisms involved, and then tailor the therapy accordingly. If any further classification is wanted, LV volume would be more relevant than ejection fraction because LV volume reflects the remodeling process, which is more important because it seems current HF treatment is most effective in hearts that have remodeled and enlarged. And so to me, at least, it would be more acceptable and preferable to talk about “HF with a big heart” or “HF with a small heart.” But no doubt this may lead to yet more debate on what is a normal LV volume!
- American College of Cardiology Foundation
- Mahadevan G.,
- Davis R.C.,
- Frenneaux M.P.,
- et al.
- ↵Oxford Dictionaries. Definition of preserve in English. Available at: http://www.oxforddictionaries.com/us/definition/american_english/preserve. Accessed December 17, 2013.
- Orwell G.