Universal definition and classification of heart failure: A step in the right direction from failure to function - American College of Cardiology (2023)

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  • The proposed universal definition describes heart failure as a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and confirmed by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion.
  • The stages of HF have been revised to emphasize the symptomatic nature of HF as a clinical syndrome: Risk of HF (stage A), pre-HF (new!) (stage B), symptomatic HF (stage C) and advanced HF (stage D).
  • Classification of HF according to LVEF now includes:
    • HFrEF: symptomatic heart failure with LVEF ≤40%
    • HFmrEF: symptomatic heart failure with LVEF 41-49%
    • HFpEF: symptomatic heart failure with LVEF ≥50%
    • HFimpEF: symptomatic heart failure with baseline LVEF ≤40%, ≥10 unit increase from baseline LVEF and other LVEF measurement >40%
  • Language counts! The new universal definition nomenclature provides opportunities to more accurately communicate and describe health and disease in HF with terms including "persistent HF" instead of "stable HF" and "HF in remission" instead of "recovered HF".

The clear definition of heart failure (HF) in clinical practice and for the purpose of clinical research can be elusive and difficult to standardize. Most definitions focus on the diagnostic features of HF as a clinical syndrome, but there is considerable heterogeneity regarding specific diagnostic criteria. In an attempt to provide more specificity, some early definitions suggested incorporating hemodynamic and metabolic concepts.1,2However, evaluation and application of such parameters can be difficult in routine clinical practice. In addition, the criteria used to define heart failure in clinical trials were highly variable, placing limitations on the collection of relevant endpoints of interest, particularly heart failure-related hospitalizations. As the burden of heart failure continues to rise and mounting evidence suggests shortcomings in the implementation of guideline-directed medical therapy (GDMT),3there was an urgent need for a universal definition of heart failure that is clinically relevant, simple, comprehensive, universally applicable and allows all stakeholders to guide, predict and guide available treatments.

In response to the need for a consensus definition for HF, in 2020 a written committee consisting of members of e.g.America's heart failure(HFSA), theHeart Failure Association of European Society of Cardiology(HFA/ESC), andHeart Failure Society of Japan(JHFS) in 14 countries and 6 continents produced a consensus document that resulted in the new global definition and classification of HF.4The proposed universal definition emphasizes that HF ​​is a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and confirmed by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic overload. The stages of heart failure have been revised to emphasize the presence (or absence) of symptoms as fundamental for characterizing disease progression and severity: Risk of heart failure (stage A), pre-AMI (stage B), symptomatic KA (stage C) ) and Advanced HF (stage D).

A revised classification of HF by left ventricular ejection fraction (LVEF) was also proposed and is as follows:

  • HF with reduced ejection fraction (HFrEF)– symptomatic heart failure with LVEF ≤40%
  • HF with mildly reduced ejection fraction (HFmrEF)– symptomatic HF with LVEF 41-49% (previously labeled HF with mid-range ejection fraction)
  • HF with preserved ejection fraction (HFpEF)– symptomatic heart failure with LVEF ≥50%
  • HF with enhanced ejection fraction (HFimpEF)– a new classification clearly defined as symptomatic heart failure with baseline LVEF ≤40%, an increase of ≥10 units from baseline LVEF and another measurement of LVEF >40%(Figure 1)

Figure 1.Courtesy of Gibson GT, Blumer V, Mentz RJ, Lala A.

The new global definition and classification of HF represents a major advance in our field. Standardizing the definition of HF is valuable for several reasons:

  • It provides multiple stakeholders, including clinicians, researchers, researchers, healthcare providers, and payers, with a comprehensive definition to define heart failure
  • inclusion of objective criteria adds significant sensitivity and specificity to the diagnosis - hopefully leading to more accurate identification and fewer misdiagnoses
  • a more standardized identification of HF increases the accuracy of performance measures, which is essential for monitoring quality improvement strategies across institutions.

Classifying heart failure by stage allows clinicians to communicate with patients in a more practical way and provide key words that allow for more effective shared decision making and care. Clinicians and patients can assess heart failure as a continuum of cardiovascular health, with indications for a focus on treatment and/or prevention depending on the stage. The pre-HF phase provides opportunities for education, addressing key risk factors, and preventing progression to symptomatic phases where HF is "active."

As heart failure patients are often underclassified according to the EC, the committee also proposed a new classification system to improve the current nomenclature. Most notable is the new subcategory 'HF with improved EF' (HFimpEF), which describes patients who have shown an improvement in EF of 10% or more to >40% compared to a baseline measurement. This characterization distinguishes patients with previously severely reduced EF from those with only mild declines at baseline and provides a sense of disease course.5This concept is of central importance as it is known that individuals with improved EF may still be at risk of recurrent ventricular dysfunction and decompensation, particularly if GDMT is discontinued.6It is also worth noting the inherent limitations of classifying individuals with HF based on EF alone, as EF is only a characterization and alone does not represent the underlying pathophysiology of a particular disease process.7

Finally, the universal definition and classification of HF acknowledges thatlanguage matters. As we aim to move away from the traditionally accepted term 'heart failure' and move towards 'cardiac function', there are other key concepts introduced by this committee which are worth noting. First, clinicians should choose the term "persistent heart failure" rather than "stable heart failure" because even in the situation of stable heart failure, there are opportunities to optimize treatments that prevent further deterioration and/or deterioration or adverse outcome. Similarly, "HF in remission" is defined as an important surrogate for the conventionally used term "recovered HF", for patients who show resolution of their symptoms and/or systolic function, as it is known that HF ​​often relapse. As cardiac function cardiologists, it is also important to convey to patients that improvement does not mean that heart failure is cured. The semantic changes and classification scheme of the new definition provide opportunities for better communication and patient engagement where clinicians can focus on implementing GDMT along a continuum to improve outcomes(Figure 1).

Overall, the new universal definition and classification of CA is simple but conceptually comprehensive, has sufficient sensitivity and specificity, with near-universal applicability, and offers great prognostic and therapeutic validity and utility. It also provides the important opportunity to recognize that the language used by healthcare professionals can have a profound impact on how people living with heart failure and their carers approach their illness.

bibliographical references

  1. Wagner S, Cohn K. Heart failure: a proposed definition and classification.Arch Intern Med1977, 137:675-78.
  2. Denolin H, Kuhn H, Krayenbuehl H, Loogen F, Reale A. The definition of heart failure.Eur Heart J1983, 4:445-48.
  3. Greene SJ, Butler J, Albert NM, et al. Medical management of heart failure with reduced ejection fraction: the CHAMP-HF registry.J Am Coll Cardiol2018; 72: 351-66.
  4. Bozkurt B, Coats AJ, Tsutsui H, et al. Universal definition and classification of heart failure: a report by the Heart Failure Society of America, the Heart Failure Society of the European Society of Cardiology, the Heart Failure Society of Japan, and the Universal Definition of Heart Failure Writing Committee.J card error2021; 27:387-413.
  5. Abramov D, Kittleson MM. The global definition of heart failure: strengths and opportunities.J card error2021; 27-622-24.
  6. Halliday BP, Wassall R, Lota AS, et al. Withdrawal of pharmacological treatment for heart failure in patients with restored dilated cardiomyopathy (TRED-HF): an open-label, pilot, randomized trial.Lancet2019; 393:61-73.
  7. Lam CSP, Yancy C. Universal definition and classification of heart failure: is it universal? Does it define heart failure?J card error2021; 27:509-11.

Clinical problems: Cardiovascular Care Team,Heart failure and cardiomyopathies,Acute heart failure

Keyword: pulse volume,syncope,patient participation,semantics,unanimity,quality improvement,decision making,Abdominal function, left,natriuretic peptides,ventricular dysfunction, left,hospitalization,risk factors,The development of the disease,diagnostic errors,Reference standards

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