Societies Publish New Universal Definition and Classification of Heart Failure

March 1, 2021—The Heart Failure Society of America (HFSA), the Heart Failure Association of the European Society of Cardiology (HFA-ESC), and the Japanese Heart Failure Society (JHFS) announced a new Universal Definition and Classification of Heart Failure, which will standardize language and practices around the definition and classification of heart failure (HF).

The Universal Definition and Classification of Heart Failure has been jointly published by Biykem Bozkurt, MD, et al in the Journal of Cardiac Failure, the official journal of the HFSA and the JHFS, and the European Journal of Heart Failure, the official journal of the HFA-ESC.

The authors proposed a universal definition of HF as:

• A clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality (as determined by ejection fraction [EF] < 50%, abnormal cardiac chamber enlargement, E/E' > 15, moderate/severe ventricular hypertrophy, or moderate/severe valvular obstructive or regurgitant lesion) and corroborated by at least one of elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion, such as imaging or hemodynamic measurement at rest of with provocation.

Additionally, the proposed revised stages of HF include:

• Stage A, At risk for HF: for patients at risk for HF but without current or previous symptoms or signs of HF and without structural or biomarker evidence of heart disease.
• Stage B, Pre HF: for patients without current or prior symptoms or signs of HF but evidence of one of structural heart disease or abnormal cardiac function or elevated natriuretic peptide levels.
• Stage C, HF: for patients with current or previous symptoms and/or signs of HF caused by a structural and/or functional cardiac abnormality.
• Stage D, Advanced HF: for patients with severe symptoms and/or signs of HF at rest, recurrent hospitalizations despite guideline-directed medical therapy (GDMT), refractory or intolerant to GDMT, requiring advanced therapies such as consideration for transplant, mechanical circulatory support, or palliative care.

The authors also proposed a new and revised classification of HF according to left ventricular ejection fraction (LVEF):

• HF with reduced ejection fraction (HFrEF): HF with LVEF ≤ 40%
• HF with mildly reduced ejection fraction (HFmrEF): HF with LVEF 41% to 49%
• HF with preserved ejection fraction (HFpEF): HF with LVEF ≥ 50%
• HF with improved ejection fraction (HFimpEF): HF with a baseline LVEF ≤ 40%, a ≥ 10-point increase from baseline LVEF, and a second measurement of LVEF > 40%.

According to the societies, the definitions of HF thus far have lacked standardization among clinicians, investigators, administrators, health care services, institutions, legislators, and payers, as well as patients and caregivers.

The societies stated that the document provides a definition that is clinically relevant and simple but conceptually comprehensive. It also offers the ability to subclassify HF within ejection fraction (EF) groups and provides a revised classification of stages of HF. The new definition and classification can be used in a standardized fashion across scientific societies and guidelines, employed by clinicians, used in research studies, and incorporated into discussions with patients and caregivers.

Dr. Bozkurt, who is Immediate Past President of the HFSA, commented in the announcement, “The release of the Universal Definition and Classification of Heart Failure marks an exciting time in the field of heart failure as we’ve been burdened with different descriptors that often cause discordance in the HF scientific community, from providers to legislators and everything in between. Also, some of the staging terminologies we had used were not clear for our patients, and classifications for EF needed further clarification for the health care professionals.

“A standard heart failure definition that’s accepted by our three societies and endorsed by many others, and classifications that are understandable by patients and clinicians will change the future of HF care, allowing us to focus on prevention strategies for patients at risk for heart failure or in pre-heart failure stages, in addition to diagnosis and treatment of patients with heart failure or advanced heart failure; and implement evidence-based strategies in a standardized manner across continents and different societies.”

In 2020, HFSA led the HFA-ESC and JHFS at the annual Trilateral International Heart Failure (TIHF) Consensus Conference to address and develop a joint publication on the universal definition and classification of heart failure. Dr. Bozkurt served as Chair of the TIHF in 2020, joined by co-chairs Professor Andrew Coats, MD, 2020-2022 President of HFA-ESC, and Hiroyuki Tsutsui, MD, President of the JHFS.

Dr. Coats stated in the announcement, “The purpose of the TIHF is to tackle critical issues facing the field of heart failure. I'm sure I speak for the leaders of HFSA and JHFS when I say HFA-ESC leaders are thrilled that we used our time together in 2020 to focus on a global consensus of the definition and classification of HF, which will certainly unite all those who are working to reduce the burden of HF around the world.”

Dr. Tsutsui added, “The additional support from societies beyond JHFS, HFSA, and HFA-ESC is incredible and serves to support the definition and classification on an even larger scale. We hope that this paper, supporting editorials, and accompanying materials will serve our field and change the future of HF care.”

The societies advised that the Universal Definition and Classification of Heart Failure has been endorsed by a number of professional societies including the Cardiac Society of Australia and New Zealand, the Chinese Heart Failure Association, the Canadian Heart Failure Society, and the Heart Failure Association of India.