From the Guidelines
Heart failure is classified into three main categories based on left ventricular ejection fraction (LVEF): heart failure with reduced ejection fraction (HFrEF) with LVEF ≤40%, heart failure with mildly reduced ejection fraction (HFmrEF) with LVEF 41-49%, and heart failure with preserved ejection fraction (HFpEF) with LVEF ≥50%. The classification of heart failure based on LVEF is crucial because it guides treatment approaches and has implications for patient outcomes, as noted in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. The main categories of heart failure are:
- HFrEF (LVEF ≤40%): characterized by systolic dysfunction, with first-line treatments including ACE inhibitors, ARBs, beta-blockers, and mineralocorticoid receptor antagonists, as well as SGLT2 inhibitors for all patients regardless of diabetes status 1.
- HFmrEF (LVEF 41-49%): may benefit from similar medications as HFrEF, but with less robust evidence, and its management is focused on improving symptoms and reducing morbidity 1.
- HFpEF (LVEF ≥50%): treatment focuses on managing symptoms and underlying conditions, with SGLT2 inhibitors showing benefit in recent studies, and diuretics used for symptom relief across all types 1. Advanced therapies for refractory HFrEF include cardiac resynchronization therapy, implantable cardioverter-defibrillators, left ventricular assist devices, and heart transplantation, highlighting the importance of accurate classification and treatment based on LVEF 1. The classification and treatment of heart failure based on LVEF have evolved over time, with recent guidelines emphasizing the importance of SGLT2 inhibitors in HFrEF and the challenges of managing HFpEF, as discussed in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. Some key points to consider in the management of heart failure include:
- The use of ACE inhibitors, ARBs, beta-blockers, and mineralocorticoid receptor antagonists in HFrEF, as recommended by the 2022 AHA/ACC/HFSA guideline 1.
- The potential benefits of SGLT2 inhibitors in HFpEF, as noted in recent studies 1.
- The importance of diuretics in managing symptoms across all types of heart failure, as discussed in the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1.
- The role of advanced therapies, such as cardiac resynchronization therapy and heart transplantation, in refractory HFrEF, as highlighted in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.
From the Research
Classifications of Heart Failure
- Heart failure (HF) can be classified based on left ventricular ejection fraction (LVEF) into several categories, including:
- Heart failure with reduced ejection fraction (HFrEF): symptomatic HF with LVEF ≤40% 2
- Heart failure with mildly reduced ejection fraction (HFmrEF): symptomatic HF with LVEF 41-49% 2
- Heart failure with preserved ejection fraction (HFpEF): symptomatic HF with LVEF ≥50% 2, 3, 4, 5
- Heart failure with improved ejection fraction (HFimpEF): symptomatic HF with a baseline LVEF ≤40%, a ≥10 point increase from baseline LVEF, and a second measurement of LVEF > 40% 2
Treatment Options
- Treatment strategies for HF vary depending on the classification:
- HFrEF: treatment includes diuretics, β-blockers, angiotensin receptor-neprilysin inhibitors, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers, with addition of a mineralocorticoid receptor antagonist in patients with persistent symptoms 6
- HFpEF: treatment includes decongestion by diuretics, promotion of a healthy active lifestyle, and management of comorbidities, with recent evidence suggesting the use of sodium-glucose cotransporter 2 inhibitors to reduce the risk of composite cardiovascular events 3, 5
- HFmrEF and HFimpEF: treatment options are less clear, but may involve a combination of therapies used for HFrEF and HFpEF 2
Stages of Heart Failure
- The stages of HF include:
- At risk for HF (Stage A)
- Pre-HF (Stage B)
- Symptomatic HF (Stage C)
- Advanced HF (Stage D) 2