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Universal Definition of Heart Failure Syndrome: Evolving Strategies

October 06, 2021.
Biykem Bozkurt, MD, PhD, FACC, Houston, TX
Allen J. Taylor, MD, FACC, Washington, DC

Educational Objectives


After completing the activity, the clinician will be better able to apply a standardized definition of heart failure in clinical practice.

Summary


Universal Definition of Heart Failure Syndrome: Evolving Strategies

Correspondent: Michelle D. Kelsey, MD, Durham, NC

Take-home Messages:

  • Despite improvements in guidelines and expansion of evidence for life-saving therapies for heart failure (HF), standard therapies (eg, angiotensin-converting enzyme [ACE] inhibitors, β-blockers) continue to be underutilized — demonstrating a lack of standardization in HF care.
  • A textbook definition of HF usually defines HF as the heart’s inability to meet the body’s metabolic demands at the tissue level (which usually applies to advanced, end-stage HF patients).
  • Practice guidelines use varying terminology and parameters to define HF, ranging from signs and symptoms, reduced cardiac output and/or elevated filling pressures, neurohormonal features, and biomarkers.
  • Inconsistencies across guidelines and unclear terminology (about, eg, HF staging nomenclature) create confusion among clinicians as well as patients.
  • The Universal Definition and Classification of Heart Failure is a consensus statement developed by the Heart Failure Society of America, the Heart Failure Association of the European Society of Cardiology, and the Japanese Heart Failure Society, and is endorsed by a number of other societies.
  • The consensus statement defines HF as a clinical syndrome with current or prior 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 cardiogenic pulmonary or systemic congestion by a diagnostic modality (eg, imaging study).
  • The document proposes revised stages of HF. At-risk for HF (former Stage A) — for patients at risk for HF without current or prior symptoms and/or signs and without structural, biomarker, or genetic markers of disease. Pre-HF (former Stage B) — for patients without current or prior symptoms and/or signs, but with evidence of structural heart disease, abnormal cardiac function, or elevated natriuretic peptide or cardiac troponin levels. HF (former stage C) — for patients with current or prior symptoms and/or signs of HF caused by a structural or functional cardiac abnormality. Advanced HF (former stage D) — for patients with severe symptoms and/or signs of HF.
  • The document also proposes revised classification of HF according to left ventricular ejection fraction (LVEF). HF with reduced ejection fraction (HFrEF) — HF with an LVEF of ≤40%. HF with mildly reduced EF — HF with an LVEF of 41% to 49%. HF with preserved EF — HF with an LVEF of ≥50%. HF with improved EF — HF with a baseline EF of ≤40% with a ≥10-point increase from baseline LVEF, and a subsequent measurement of LVEF >40%.
  • The consensus statement specifies terminology for clinical trajectories. For example, use of the term “persistent HF” is preferred over “stable HF,” and “HF in remission” is preferred over “recovered HF.”
  • A consensus on HF across different specialties and practitioners will support early and clear detection of HF and an improved understanding of treatment strategies (eg, sodium-glucose cotransporter-2 inhibitors, mineralocorticoid receptor antagonists) based on LVEF.
  • Implementation of the universal definition of HF requires the alignment between administrative tools, performance measures, administrative databases, registries, research initiatives, clinical practices, and the use of standardized terminologies.
  • Clinicians and patients must be educated about new terminology and HF staging, particularly for the pre-HF stage, when screening and HF prevention strategies can be initiated.

References

1. Bozkurt B, Coats AJ, Tsutsui H, et al. 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 [published online ahead of print, 2021 Mar 1]. J Card Fail. 2021;S1071-9164(21)00050-6. doi:10.1016/j.cardfail.2021.01.022

2. Bozkurt B, Coats AJS, Tsutsui H, et al. 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: endorsed by the Canadian Heart Failure Society, Heart Failure Association of India, Cardiac Society of Australia and New Zealand, and Chinese Heart Failure Association. Eur J Heart Fail. 2021;23(3):352-380. doi:10.1002/ejhf.2115

Readings


Disclosures


Biykem Bozkurt: Consultant Fees/Honoraria: Amgen Inc., Baxter Healthcare, Bristol Myers Squibb/E.R. Squibb & Sons, Vifor Pharma, Sanofi-Aventis, scPharmaceuticals; Data Safety Monitoring Board: LivaNova USA; Other: Abbott Laboratories, Respicardia.

Allen J. Taylor: Speaker’s Bureau: Amgen Inc.

Acknowledgements


CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

AC531001

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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