What is universal definition and classification of heart failure?

What is universal definition and classification of heart failure?

Over the years there have been several definitions for heart failure leading to non-uniformity in the literature on heart failure. To bring uniformity, especially for heart failure clinical trials and registries, a universal definition and classification has been published by a joint writing committee of Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology and Japanese Heart Failure Society [1]. The definition has been endorsed by major heart failure societies world wide.

The joint writing committee defines heart failure as: “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”. Just as the universal definition of myocardial infarction includes cardiac troponins [2], this universal definition of heart failure includes natriuretic peptides.

The staging of heart failure has also been revised by the joint writing committee. According to the revised version, Stage A is those ‘At risk of heart failure‘ without current or prior symptoms or signs of heart failure. They do not have structural or biomarker evidence of heart disease. Stage B ‘Pre-heart failure‘ is also for patients without current or prior symptoms or signs of heart failure. But they have evidence of structural heart disease or abnormal cardiac function, or elevated natriuretic peptide levels. Stage C is ‘Heart failure‘ with current or prior symptoms and/or signs of heart failure caused by a structural and/or functional cardiac abnormality. Stage D is ‘Advanced heart failure‘ with severe symptoms and/or signs of heart failure 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.

In addition to the universal definition and revised staging of heart failure, the joint writing committee has also proposed a new and revised classification of heart failure according to left ventricular ejection fraction as well. Heart failure with reduced ejection fraction (HFrEF) is defined as heart failure with a left ventricular ejection fraction of 40% or less. Heart failure with mildly reduced ejection fraction (HFmrEF) is heart failure with left ventricular ejection fraction from 41% to 49%. Heart failure with preserved ejection fraction (HFpEF) is heart failure with left ventricular ejection fraction of 50% or more. Heart failure with improved ejection fraction (HFimpEF) is heart failure with a baseline left ventricular ejection fraction of 40% or less, a 10 point or more increase from baseline left ventricular ejection fraction, and a second measurement of left ventricular ejection fraction of more than 40%.

Natriuretic peptides in the definition are brain natriuretic peptide (BNP) and N-terminal prohormone of brain natriuretic peptide (NT-proBNP). They are an integral component in the diagnosis of heart failure. In addition, the authors have given a list of typical and less typical symptoms of heart failure. Signs of heart failure have been given as those which are more specific and less specific. Free access to full text of the article is available at Journal of Cardiac Failure website. Though it is a big list, it is worth reading for every clinician and other persons involved in the care of heart failure patients.

References

1. Bozkurt B, Coats AJ, Tsutsui H, Abdelhamid M, Adamopoulos S, Albert N, Anker SD, Atherton J, Böhm M, Butler J, Drazner MH, Felker GM, Filippatos G, Fonarow GC, Fiuzat M, Gomez-Mesa JE, Heidenreich P, Imamura T, Januzzi J, Jankowska EA, Khazanie P, Kinugawa K, Lam CSP, Matsue Y, Metra M, Ohtani T, Francesco Piepoli M, Ponikowski P, Rosano GMC, Sakata Y, SeferoviĆ P, Starling RC, Teerlink JR, Vardeny O, Yamamoto K, Yancy C, Zhang J, Zieroth S. Universal Definition and Classification of Heart Failure: A Report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure. J Card Fail. 2021 Mar 1:S1071-9164(21)00050-6. doi: 10.1016/j.cardfail.2021.01.022. Epub ahead of print. PMID: 33663906.
2. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, White HD; Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol. 2018 Oct 30;72(18):2231-2264. doi: 10.1016/j.jacc.2018.08.1038. Epub 2018 Aug 25. PMID: 30153967.