What are the different types of heart failure and their corresponding treatments?

Types of Heart Failure and Their Treatments

Classification by Left Ventricular Ejection Fraction

Heart failure is classified into four distinct categories based on left ventricular ejection fraction (LVEF), with each category having specific diagnostic criteria and evidence-based treatments that directly impact mortality and morbidity. 1, 2

Heart Failure with Reduced Ejection Fraction (HFrEF)

• Definition: LVEF ≤40% with typical HF symptoms (breathlessness, ankle swelling, fatigue) and signs (elevated jugular venous pressure, pulmonary crackles, peripheral edema) 1, 2

• Underlying pathology: Most commonly caused by coronary artery disease (68% of cases), dilated cardiomyopathy, or prior myocardial infarction 1, 3

Guideline-Directed Medical Therapy for HFrEF (Four Pillars):

All four medication classes should be initiated and uptitrated to target doses to reduce mortality and hospitalization: 1

1. SGLT2 inhibitors (Class 1A recommendation) - initiate regardless of diabetes status 1

2. Angiotensin receptor-neprilysin inhibitor (ARNI) such as sacubitril-valsartan (Class 1A recommendation), or if not tolerated, ACE inhibitors or ARBs 1

3. Beta-blockers (Class 1A recommendation) - carvedilol, metoprolol succinate, or bisoprolol 1

4. Mineralocorticoid receptor antagonists (MRA) (Class 1A recommendation) - spironolactone or eplerenone 1

Additional HFrEF Therapies:

• Ivabradine for patients in sinus rhythm with heart rate ≥70 bpm despite maximally tolerated beta-blocker doses (Class IIa recommendation) 1, 3

• Hydralazine plus isosorbide dinitrate for African American patients on GDMT (Class 1A recommendation per ACC/AHA/HFSA) or as alternative when ARNI/ACE-I/ARB contraindicated 1

• Cardiac resynchronization therapy (CRT) for LVEF ≤35%, NYHA class II-IV, and QRS duration ≥150 ms with left bundle branch block morphology 1

• Implantable cardioverter-defibrillator (ICD) for primary prevention in patients with LVEF ≤35% despite ≥3 months of optimal medical therapy 1

Heart Failure with Mildly Reduced Ejection Fraction (HFmrEF)

• Definition: LVEF 41-49% with typical HF symptoms/signs and elevated natriuretic peptides (BNP ≥35 pg/mL or NT-proBNP ≥125 pg/mL) 1, 2

• Pathophysiology: Primarily mild systolic dysfunction with features of diastolic dysfunction 1

Treatment for HFmrEF:

• SGLT2 inhibitors (Class 2a recommendation) - strongest evidence in this category 1

• ARNI, ACE inhibitors, ARBs, MRA, and beta-blockers (Class 2b recommendations) - weaker evidence but reasonable to use based on extrapolation from HFrEF trials 1

• Diuretics for volume management as needed 1

Heart Failure with Preserved Ejection Fraction (HFpEF)

• Definition: LVEF ≥50% with typical HF symptoms/signs, elevated natriuretic peptides, and objective evidence of structural heart disease (left ventricular hypertrophy, left atrial enlargement) or diastolic dysfunction 1, 2

• Epidemiology: Represents approximately 50% of all HF cases, more common in women and patients over 75 years old 4

Treatment for HFpEF:

• SGLT2 inhibitors (Class 2a recommendation) - most robust evidence for mortality/morbidity benefit 1

• Treatment of hypertension (Class 1 recommendation) - essential for preventing disease progression 1

• Mineralocorticoid receptor antagonists (Class 2b recommendation) - spironolactone may reduce hospitalizations 1

• ARNI (Class 2b recommendation) - sacubitril-valsartan may reduce NT-proBNP levels and hospitalizations 1, 5

• ARBs (Class 2b recommendation) - candesartan as alternative 1

• Treatment of atrial fibrillation with rate or rhythm control (Class 2a recommendation) 1

• Diuretics for congestion - loop diuretics at doses equal to or exceeding chronic oral doses during acute decompensation 1, 5

• Avoid routine use of nitrates or phosphodiesterase-5 inhibitors (Class 3: No Benefit) 1

Heart Failure with Improved Ejection Fraction (HFimpEF)

• Definition: Previous HFrEF (LVEF ≤40%) with ≥10-point increase in LVEF and second measurement >40% 1, 2

• Critical management principle: Continue all HFrEF therapies despite LVEF improvement, as discontinuation leads to worse outcomes and potential relapse 1

Classification by Time Course

Acute Heart Failure

• New-onset ("de novo") HF: Presents acutely (e.g., acute myocardial infarction) or subacutely (e.g., dilated cardiomyopathy) 1

• Acute decompensated chronic HF: Previously stable chronic HF that deteriorates suddenly or gradually, often requiring hospitalization 1

Acute HF Management:

• Immediate IV loop diuretics at doses equal to or exceeding chronic oral daily dose 5

• Continue beta-blockers and RAAS inhibitors unless marked volume overload or recent initiation 5, 6

• Monitor daily weights, electrolytes, renal function during aggressive diuresis 5

• Avoid routine invasive hemodynamic monitoring in normotensive patients responding to initial therapy 5

Chronic Stable Heart Failure

• Definition: Symptoms and signs unchanged for at least 1 month on stable medical regimen 1

• Management: Optimize GDMT with uptitration to target doses, manage comorbidities, and monitor for decompensation 1

Advanced Heart Failure (Stage D)

• Definition: Severe symptoms at rest (NYHA class IV), recurrent hospitalizations despite GDMT, refractory to or intolerant of GDMT 1, 2

• Management: Referral to HF specialty team for consideration of advanced therapies including mechanical circulatory support, heart transplantation, or palliative care 1, 2

Classification by Symptom Severity (NYHA Functional Class)

• Class I: No limitation of physical activity; ordinary activity does not cause symptoms 1

• Class II: Slight limitation of physical activity; comfortable at rest but ordinary activity causes symptoms 1

• Class III: Marked limitation of physical activity; comfortable at rest but less than ordinary activity causes symptoms 1

• Class IV: Unable to carry out any physical activity without symptoms; symptoms present at rest 1

Common Pitfalls to Avoid

• Do not withhold beta-blockers during acute decompensation unless marked volume overload or recent initiation, as this worsens outcomes 5, 6

• Do not discontinue HFrEF therapies when LVEF improves above 40%, as patients remain at risk for relapse 1

• Do not interpret elevated troponin in acute HF as requiring emergent catheterization unless ECG changes or clinical features suggest acute coronary syndrome 5

• Do not assume low BNP excludes HFpEF, especially in obese patients 7

• Do not delay aggressive diuresis while waiting for additional testing in acute decompensated HF 5