Instant tests: Could EF be the next vital sign?

Ejection fraction (EF) is the percentage of heart function. An ejection fraction of 40% or less signifies heart failure. While a normal EF is 55% to 70%.

Heart failure has a 50% mortality at 5 years. A prognosis that is worse than some cancers. The problem with chronic heart failure is that it tends to creep slowly and may not be detected until the symptoms are far gone.

Heart failure, like any pump failure, has the problem of a backlog. If a plumbing pump fails, there is a high probability of flooding. If the heart fails there is the high probability of flooding and waterlogging of the lungs (known as pulmonary edema).

Chronic pulmonary edema is manifested by shortness of breath at rest and on minimal exertion, chronic cough of frothy sputum or phlegm, inability to lay flat (orthopnea) and suddenly waking up from lying down (paroxysmal nocturnal dyspnea).

The liver becomes congested from the backlog and pump failure leading to yellowing of the eyes; the bowel is also congested causing nausea, and constipation; the legs are swollen, so also scrotal swelling, and fluid accumulation in the subcutaneous tissues of the low back. In addition, cardiac pump failure leads to a low perfusion state of vital organs such as kidneys and brain.

Imagine a scenario in a resource-limited setting with the usual vital signs of blood pressure, heart rate, respiratory rate, pulse oximeter, temperature, height and weight, that an additional piece of information is added called the EF (Ejection fraction) allowing diagnoses such as early heart failure from hypertension, valvular heart disease, cardiomyopathy, or postpartum cardiomyopathy.

An abnormal EF will lead to intensive treatment regimens, that can potentially improve or reverse the onset of heart failure. Imagine a person with blood pressure “off the charts”, for example, a systolic blood pressure of 220 mmHg (Normal is 120 mmHg) who feels fine and feels no compelling reason to take blood pressure medications. Imagine an EF report that is low and thus sends a signal of urgency to make it clear that silent target organ damage has set in. This could motivate medication compliance even in the most resistant person.

Last year, I submitted a pitch for a start-up for portable ECHOs in suburban and rural areas in Nigeria. The idea of this pitch was to obtain portable ECHOs that could be performed by a trained Nurse technician and beamed remotely to a cardiologist abroad to provide a reading, that could then be used to stratify risk and provide appropriate care to those in heart failure.

The economic impact was less sick days, less utilization of health care resources and improved productivity. My team and I did not win the pitch. I was disappointed. Without the win, the idea just fizzled away and dried up like a raisin.

Fast forward a year later, health technology is leading the way. The good news is the FDA’s new “breakthrough” designation program that has recently approved devices and software for easier detection of cardiac conditions through artificial intelligence algorithm protocols.

Hopefully, these technologies will be available and affordable in due course in resource-limited settings where point-of-care testing can lead to therapeutic interventions that would prolong and improve quality of life. Perhaps EF will indeed become another vital sign.

Written by Dr. N. Onuoha.

Image from Godaddy stock photos

References:

https://www.ekohealth.com/blog/fda-clears-afib-and-heart-murmur-detection-algorithms

https://www.fda.gov/news-events/press-announcements/fda-authorizes-marketing-first-cardiac-ultrasound-software-uses-artificial-intelligence-guide-user

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