Echocardiographic Criteria for Stage B Heart Failure
Stage B heart failure is defined by structural heart disease without current or previous symptoms or signs of heart failure, with evidence of at least one of the following on echocardiography: reduced left ventricular systolic function, ventricular hypertrophy, chamber enlargement, wall motion abnormalities, or valvular heart disease. 1
Definition and Diagnostic Framework
- Stage B heart failure represents the "pre-heart failure" stage where patients have structural heart disease but no current or prior symptoms or signs of heart failure 2, 3
- Echocardiography is essential for diagnosing Stage B heart failure as it provides assessment of cardiac chamber size, structure, ventricular function, and valvular function 4
- The 2022 ACC/AHA/HFSA guidelines expanded the definition of Stage B heart failure to include objective evidence of increased filling pressures and biomarker criteria 1
Specific Echocardiographic Criteria for Stage B Heart Failure
Left Ventricular Systolic Function Parameters
- Left ventricular ejection fraction (LVEF) ≤40% (defining HFrEF) without symptoms 5, 2
- LVEF 41-49% (defining HFmrEF) without symptoms 5
- Reduced left ventricular strain despite normal LVEF 1
- Wall motion abnormalities suggesting previous myocardial damage 1
Structural Abnormalities
- Left ventricular hypertrophy (increased LV mass index) 5, 1
- Chamber enlargement (increased left atrial volume index and/or left ventricular dimensions) 5, 1
- Valvular heart disease that could lead to heart failure 1
Evidence of Increased Filling Pressures
- Elevated E/e' ratio >9 on echocardiography (suggesting elevated LV filling pressures) 5
- Echocardiographic pulmonary artery systolic pressure >35 mm Hg 5
- Evidence of diastolic dysfunction 6
Clinical Implications and Management
- Patients with Stage B heart failure require regular monitoring with serial echocardiography to assess for progression to symptomatic heart failure 1
- ACE inhibitors or ARBs are recommended in patients with a history of MI and reduced EF to prevent progression to symptomatic heart failure 1
- Evidence-based beta blockers are recommended in patients with MI and reduced EF 1
- Global longitudinal strain (GLS) assessment by 2D speckle-tracking may provide additional prognostic information beyond LVEF 6, 7
Important Considerations and Pitfalls
- LVEF alone is insufficient for comprehensive risk assessment; a complete echocardiographic evaluation including systolic, diastolic, left atrial, and right ventricular function is beneficial 6
- Nondihydropyridine calcium channel blockers with negative inotropic effects should be avoided in patients with low LVEF as they may be harmful 1
- Serial echocardiographic assessment is important as changes in LVEF might not be unidirectional; patients may experience improvement followed by decrease in EF or vice versa 5
- Trajectory of LVEF is important, and a significant reduction in LVEF over time is a poor prognostic factor 5
Monitoring Recommendations
- Regular echocardiographic monitoring is essential to detect progression from Stage B to symptomatic heart failure (Stage C) 1
- Assessment of both systolic and diastolic parameters provides more comprehensive risk stratification than LVEF alone 6, 7
- Monitoring for development of valvular disease progression is important as it may contribute to heart failure development 1