Perspective:

This is an interesting and statistically well analyzed population study from a well-known cohort of patients. Not surprisingly, patients with pre-existing ‘asymptomatic’ LV systolic or diastolic abnormalities on echo go on to develop symptoms or signs of HF. Baseline medical therapies prescribed to these patients with asymptomatic disease were not presented nor do we know the true definition of ‘asymptomatic,’ but the information gleaned is important and supports the need for aggressive medical management according to American College of Cardiology Foundation/American Heart Association guidelines. The Framingham HF criteria are biased against identifying class I-II HF patients. Framingham criteria include exam signs like rales, jugular venous distention, paroxysmal nocturnal dyspnea, and tachycardia >120 bpm, which are associated with marked HF decompensation. Thus, this study actually suggests ‘asymptomatic’ dysfunction predisposes to the development of advanced clinical HF. The authors also demonstrated that the presence of other medical comorbidities is associated with increased risk for HF development. In the chronic obstructive pulmonary disease (COPD) patient, one could argue that it may be hard to tease out diagnoses (COPD vs. HF) using some of the Framingham exam criteria (e.g., dyspnea on exertion, nocturnal cough, decreased vital capacity). Statistically, the authors controlled for potential confounders (such as diabetes, prior myocardial infarction, and hypertension) that may be present in greater burden in the COPD or renal failure patient. Further studies, however, are needed establish causality and explain the ‘link.’