Heart failure with reduced ejection fraction

Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.

Heart failure with reduced ejection fraction (HFrEF) is HF with left ventricular ejection fraction (LVEF) of 40% or less.

Heart failure with mildly reduced EF (HFmrEF) is HF with LVEF 41% to 49%.

HF is a major and growing public health problem. It is the only cardiovascular disease that is increasing in incidence and prevalence, partly because the population is ageing, but also because of improved cardiovascular interventions for disease processes that reduce early mortality but may result in cardiac changes that lead to heart failure.

The key manifestations are dyspnoea and fatigue, which may limit exercise tolerance, and fluid retention, which may lead to pulmonary congestion and peripheral oedema.

The single most useful diagnostic test in the evaluation of patients is the comprehensive 2-dimensional echocardiogram coupled with Doppler flow studies. Measurement of B-type natriuretic peptide can be useful in the evaluation of patients at initial presentation.

Interventions that have a proven beneficial impact on patient survival include angiotensin receptor-neprilysin inhibitors, ACE inhibitors, angiotensin-II receptor antagonists, beta-blockers, aldosterone antagonists, sodium-glucose cotransporter-2 inhibitors, hydralazine and nitrates, cardiac re-synchronisation therapy, and implantable cardioverter-defibrillators.

Comorbidity is common, with most HF patients having at least one comorbid condition such as obesity or coronary artery disease.

Heart failure (HF) is a condition in which the heart is unable to generate a cardiac output sufficient to meet the demands of the body without increasing diastolic pressure. It can result from any cardiac disease that compromises ventricular systolic or diastolic function or both. A universal definition of HF, proposed in 2021 by the Heart Failure Society of America, the Heart Failure Association of the European Society of Cardiology, and the Japanese Heart Failure Society, describes HF as "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".[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. J Card Fail. 2021 Apr 1;27(4):387-413. https://www.onlinejcf.com/article/S1071-9164(21)00050-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/33663906?tool=bestpractice.com

In clinical practice, the term 'congestive heart failure' is usually used for patients with breathlessness and abnormal sodium and water retention, resulting in oedema. However, the term 'congestive' has been removed from the universal definition, as a reminder that there is a wide range of symptoms and signs once the patient is diagnosed with HF.[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. J Card Fail. 2021 Apr 1;27(4):387-413. https://www.onlinejcf.com/article/S1071-9164(21)00050-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/33663906?tool=bestpractice.com

HF comprises a wide range of clinical scenarios, from patients with preserved left ventricular ejection fraction (LVEF ≥50%) to those with reduced myocardial contractility (LVEF <40%).

Based on LVEF, the universal definition classifies HF as follows:​[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. J Card Fail. 2021 Apr 1;27(4):387-413. https://www.onlinejcf.com/article/S1071-9164(21)00050-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/33663906?tool=bestpractice.com

1. HF with reduced ejection fraction (HFrEF): HF with LVEF ≤40%.

2. HF with mildly reduced EF (HFmrEF): HF with LVEF 41% to 49%.

3. HF with preserved EF (HFpEF): HF with LVEF ≥50%; for more information on this, see Heart failure with preserved ejection fraction.

4. 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%.

Advanced HF is defined as having severe symptoms and/or signs of HF at rest, recurrent hospitalisations despite guideline-directed medical therapy (GDMT), being refractory or intolerant to GDMT, and requiring advanced therapies such as consideration for transplantation, mechanical circulatory support, or palliative care.[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. J Card Fail. 2021 Apr 1;27(4):387-413. https://www.onlinejcf.com/article/S1071-9164(21)00050-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/33663906?tool=bestpractice.com