Heart failure

Landmark new heart failure definition will change diagnosis and treatment

A new international consensus statement has redefined the classification and staging of heart failure into a more standardised and rational system and is being described as a ‘landmark’  change in the diagnosis and management of the condition.

The new document “Universal Definition and Classification of Heart Failure” has been developed by the Heart Failure Society of America and the Heart Failure Association of the European Society of Cardiology, and has been endorsed by international professional groups including the CSANZ.

Its authors said new definitions were long overdue because the current system was inconsistent, sometimes based on diagnosis and sometimes on haemodynamics. The new system provides a comprehensive but simple framework of heart failure based on revised staging A to D for severity, with stage B now representing “pre-heart failure” (no current or prior symptoms but evidence of abnormal structural, functional, or biomarker measures) and stage C now inclusive of heart failure in remission and persistent heart failure.

The new universal definition of heart failure is: “a clinical syndrome with symptoms and or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and or objective evidence of pulmonary or systemic congestion.”

The four stages of HF are:

At-risk for HF (Stage A): people at risk for HF but without current or prior symptoms or signs of HF and without structural or biomarkers evidence of heart disease.

Pre-HF (Stage B): patients without current or prior symptoms or signs of HF, but evidence of structural heart disease or abnormal cardiac function, or elevated natriuretic peptide levels.

HF (Stage C): patients with current or prior symptoms and/or signs of HF caused by a structural and/or functional cardiac abnormality.

Advanced HF (Stage D): patients with severe symptoms and/or signs of HF at rest, recurrent hospitalizations despite guideline-directed management and therapy (GDMT), refractory or intolerant to GDMT, requiring advanced therapies such as consideration for transplant, mechanical circulatory support, or palliative care.

The new consensus statement also proposes a new classification of HF based on ejection fraction, corresponding  to define groups where treatment differs.

The four revised classifications are:

HF with reduced EF (HFrEF):  HF with an LVEF of ≤40%;

HF with mildly reduced EF (HFmrEF):  HF with an LVEF of 41-49%;

HF with preserved EF (HFpEF): HF with an LVEF of ≥50%;

HF with improved EF (HFimpEF): HF with a baseline LVEF of ≤40%, a ≥10-point increase from baseline LVEF, and a second measurement of LVEF of >40%.

The authors say they hope the new definitions will also assist non-cardiologists, particularly in the early identification of at-risk patients and provision of interventions to  prevent or delay the development of HF/

They said it was critically important “to recognize that pre-HF patients, such as asymptomatic patients with elevated natriuretic peptide levels likely will require referral to a cardiologist for further diagnostic and treatment strategies to prevent progression of HF; that the diagnosis and timely treatment of HF should not be missed or delayed in patients with symptoms and signs of HF; and that elevated natriuretic peptide levels or patients with evidence of systemic or pulmonary congestion/elevated filling pressures, and patients with advanced HF would be considered for referral to HF specialists according to their goals.”

An accompanying commentary described the new definition as a landmark and a “tremendous opportunity (and responsibility) to fully address [the definition’s] potential impact for the future of heart failure clinical care, research, and advocacy.”

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