Recommended Format for Writing a Heart Failure Diagnosis
The diagnosis of heart failure should include the ejection fraction category, stage of heart failure, and underlying etiology to guide appropriate treatment and improve patient outcomes. 1
Classification by Ejection Fraction
Heart failure should be categorized based on left ventricular ejection fraction (LVEF) as follows:
- HF with reduced EF (HFrEF): Heart failure with LVEF ≤40% 1, 2
- HF with mildly reduced EF (HFmrEF): Heart failure with LVEF 41-49% 1, 3
- HF with preserved EF (HFpEF): Heart failure with LVEF ≥50% 1, 4
- HF with improved EF (HFimpEF): Heart failure with baseline LVEF ≤40%, a ≥10-point increase from baseline, and a second measurement of LVEF >40% 2, 5
Staging of Heart Failure
Include the appropriate stage according to the Universal Definition of Heart Failure:
- Stage A: At risk for HF but without current/prior symptoms or structural heart disease 2, 5
- Stage B: Pre-HF - no current/prior symptoms but evidence of structural heart disease or abnormal cardiac function 2, 5
- Stage C: Current or prior symptoms and/or signs of HF caused by structural/functional cardiac abnormality 2, 5
- Stage D: Advanced HF with severe symptoms at rest, recurrent hospitalizations despite guideline-directed therapy 2, 5
Underlying Etiology
Specify the underlying cause(s) of heart failure, which may include:
- Ischemic heart disease: Myocardial scar, stunning/hibernation, coronary artery disease 1
- Hypertension: Leading to left ventricular hypertrophy and diastolic dysfunction 1, 6
- Valvular heart disease: Mitral, aortic, tricuspid, or pulmonary valve abnormalities 1
- Cardiomyopathies: Dilated, hypertrophic, restrictive, arrhythmogenic right ventricular 1
- Toxic damage: Alcohol, drugs, chemotherapy agents 1
- Arrhythmias: Tachyarrhythmias or bradyarrhythmias 1
- Metabolic disorders: Diabetes, thyroid disease 1
- Infiltrative diseases: Amyloidosis, sarcoidosis, hemochromatosis 1, 4
Functional Status
Include the New York Heart Association (NYHA) functional classification:
- Class I: No limitation of physical activity 1
- Class II: Slight limitation of physical activity 1
- Class III: Marked limitation of physical activity 1
- Class IV: Unable to carry out any physical activity without symptoms 1
Diagnostic Evidence
Document the objective evidence supporting the diagnosis:
- Symptoms/signs: Breathlessness, ankle swelling, fatigue, elevated jugular venous pressure, pulmonary crackles, peripheral edema 1
- Biomarkers: BNP >35 pg/mL or NT-proBNP >125 pg/mL (non-acute setting) 1
- Imaging findings: Structural/functional cardiac abnormalities on echocardiography 1
- Hemodynamic data: If available, especially for HFpEF diagnosis 1, 4
Example Format
"Heart failure with [EF category] (LVEF XX%), Stage [A-D], NYHA Class [I-IV], due to [underlying etiology], with [relevant symptoms/signs], confirmed by [diagnostic evidence]."
Common Pitfalls to Avoid
- Incomplete classification: Failing to specify both EF category and stage leads to suboptimal treatment decisions 1, 2
- Missing etiology: Identification of the underlying cardiac problem is crucial for therapeutic decisions 1
- Overlooking HFpEF: This diagnosis requires symptoms/signs of HF, preserved EF, elevated natriuretic peptides, and evidence of cardiac dysfunction 1, 4
- Neglecting comorbidities: Important contributors to symptoms and outcomes, especially in HFpEF 6, 7
- Ignoring functional status: NYHA classification helps guide therapy and assess prognosis 1
By following this comprehensive format, clinicians can ensure accurate diagnosis documentation that facilitates appropriate treatment selection and monitoring of heart failure patients.