From the Guidelines
Heart failure is primarily classified into four types based on left ventricular ejection fraction (LVEF): HFrEF (LVEF ≤40%), HFmrEF (LVEF 41%–49%), HFpEF (LVEF ≥50%), and HFimpEF (previous LVEF ≤40% and a follow-up measurement of LVEF >40%). These classifications are crucial for guiding treatment and management decisions, as they reflect different pathophysiological mechanisms and prognoses 1.
Key Classification Criteria
- HFrEF: Characterized by a reduced LVEF (≤40%), indicating systolic dysfunction where the heart cannot contract effectively.
- HFmrEF: Represents a mid-range ejection fraction (41%–49%), falling between HFrEF and HFpEF, and may exhibit both systolic and diastolic dysfunction.
- HFpEF: Defined by a preserved LVEF (≥50%), suggesting diastolic dysfunction where the heart cannot relax properly between beats.
- HFimpEF: Indicates an improvement in LVEF from a previously reduced level to above 40%, reflecting potential recovery or improvement in cardiac function.
Clinical Implications
Understanding these classifications is vital for clinicians to tailor treatment strategies, including the use of medications such as ACE inhibitors, beta-blockers, diuretics, and aldosterone antagonists, as well as lifestyle modifications like sodium restriction, fluid management, and regular physical activity 2, 3. The choice of therapy depends on the specific type of heart failure, with the goal of improving symptoms, reducing morbidity and mortality, and enhancing quality of life.
Recent Guidelines and Recommendations
Recent guidelines, such as those from the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines, emphasize the importance of EF-based classification for the diagnosis and management of heart failure 1, 3. Additionally, systematic reviews on the management of HFpEF highlight the role of newer therapies, such as SGLT2 inhibitors, in reducing adverse outcomes in patients with preserved ejection fraction 2.
Conclusion Not Applicable - Direct Answer Only
The classification of heart failure into HFrEF, HFmrEF, HFpEF, and HFimpEF based on LVEF is fundamental for clinical practice, guiding both the initiation of appropriate therapy and the monitoring of disease progression or improvement 1.
From the Research
Types of Heart Failure
- Heart failure with preserved ejection fraction (HFpEF): approximately 50% of patients with heart failure have HFpEF, and the incidence is increasing relative to heart failure with reduced ejection fraction (HFrEF) 4, 5, 6.
- Heart failure with reduced ejection fraction (HFrEF): associated with reduced survival and increased risk for hospitalization, and has approved treatments specifically indicated for this condition 4, 7.
- Heart failure with borderline ejection fraction (HFbEF): defined as an ejection fraction between 41% and 49%, and has similar 5-year mortality rates to HFpEF and HFrEF 7.
Characteristics of Heart Failure Types
- HFpEF: complex pathophysiology, dominant mechanisms leading to symptoms of heart failure often vary between patients, and no proven effective treatment 5, 6, 8.
- HFrEF: has approved treatments, but still associated with reduced survival and increased risk for hospitalization 4, 7.
- HFbEF: has similar 5-year mortality rates to HFpEF and HFrEF, and higher cardiovascular and heart failure readmission rates compared to HFpEF 7.
Diagnosis and Treatment
- Diagnosis of HFpEF: relies on signs and symptoms of heart failure, preserved ejection fraction, and detection of diastolic function abnormalities based on echocardiographic findings and abnormally elevated natriuretic peptide levels or invasive measurements of wedge pressure at rest or with exercise 8.
- Treatment of HFpEF: currently focused on management of symptoms and comorbidities, with no approved treatments specifically indicated for this condition 4, 5, 6.