Criteria
Universal definition and classification of heart failure[1]
Definition
Heart failure is a clinical syndrome with current or prior:
Symptoms and/or signs caused by a structural and/or functional cardiac abnormality
And corroborated by at least one of:
Elevated natriuretic peptide levels
Objective evidence of pulmonary or systemic congestion.
Stages of heart failure:
At risk for heart failure (stage A): includes patients without current or prior symptoms or signs of heart failure, structural cardiac changes, or elevated biomarkers of heart disease, but who are at risk for heart failure
Pre-heart failure (stage B): includes patients without current or prior symptoms or signs of heart failure, but who have evidence of either structural heart disease, abnormal cardiac function, or elevated natriuretic peptide or cardiac troponin
Heart failure (stage C): includes patients with current or prior symptoms and/or signs of heart failure caused by a structural and/or functional cardiac abnormality
Advanced heart failure (stage D): includes patients with severe symptoms and/or signs of heart failure at rest, recurrent hospitalizations despite guideline-directed medical therapy (GDMT), refractory or intolerant to GDMT, requiring advanced therapies such as consideration for transplantation, mechanical circulatory support, or palliative care.
Classification of left ventricular ejection fraction (LVEF):
Heart failure with reduced ejection fraction (HFrEF): symptomatic heart failure with LVEF ≤40%
Heart failure with mildly reduced ejection fraction (HFmrEF): symptomatic heart failure with LVEF 41% to 49% (previously labeled as heart failure with mid-range ejection fraction)
Heart failure with preserved ejection fraction (HFpEF): symptomatic heart failure with LVEF ≥50%
Heart failure with improved ejection fraction (HFimpEF): symptomatic heart failure with a baseline LVEF ≤40%, a ≥10-point increase from baseline LVEF, and a second measurement of LVEF >40%.
American Heart Association/American College of Cardiology/Heart Failure Society of America[3]
Stages of heart failure:
At risk for heart failure (stage A): includes patients who do not have current or prior symptoms or signs of heart failure, structural or functional cardiac changes, or abnormal biomarkers, but who are at risk for heart failure (e.g., hypertension, cardiovascular disease, obesity, family history or genetic variant for cardiomyopathy, exposure to cardiotoxic agents)
Pre-heart failure (stage B): includes patients who do not have current or prior symptoms or signs of heart failure, but who do have evidence of either structural heart disease; increased filling pressures; or risk factors with either elevated natriuretic peptide or cardiac troponin in the absence of competing diagnoses
Symptomatic heart failure (stage C): includes patients with current or prior symptoms and/or signs of heart failure
Advanced heart failure (stage D): includes patients with marked symptoms of heart failure that interfere with daily life and with recurrent hospitalizations despite attempts to optimize GDMT.
HFpEF: LVEF ≥50% with evidence of spontaneous or provokable increased LV filling pressures (e.g., elevated natriuretic peptide, noninvasive and invasive hemodynamic measurement). Suggested thresholds for evidence of increased filling pressures:
Average E/e′ ≥15
Septal e′ <7 cm/s
Lateral e′ <10 cm/s
TR velocity >2.8 m/s
Estimated PA systolic pressure >35 mmHg
BNP ≥35 picograms/mL*
NT-pro-BNP ≥125 picograms/mL*
*Cutoffs provided for natriuretic peptide levels may have lower specificity, especially in older patients or in patients with atrial fibrillation or chronic kidney disease. Usually, higher cutoff values are recommended for the diagnosis of heart failure in these patients.
2021 European Society of Cardiology Guidelines for the diagnosis and treatment of acute and chronic heart failure[4]
Diagnostic criteria for HFpEF:
Symptoms and signs of heart failure
An LVEF ≥50%*
Objective evidence of cardiac structural and/or functional abnormalities consistent with the presence of LV diastolic dysfunction/raised LV filling pressures, including raised natriuretic peptides
LV mass index ≥95 g/m² (female), ≥115 g/m² (male)
Relative wall thickness >0.42
LA volume index >34 mL/m² (sinus rhythm)
E/e’ ratio at rest >9
NT-pro-BNP >125 (sinus rhythm) or >365 (atrial fibrillation) picograms/mL
BNP >35 (sinus rhythm) or >105 (atrial fibrillation) picograms/mL
PA systolic pressure >35 mmHg
TR velocity at rest >2.8 m/s
*Patients with a history of overtly reduced LVEF (≤40%),who later present with LVEF ≥50%, should be considered to have recovered HFrEF or "heart failure with improved LVEF" (rather than HFpEF).
New York Heart Association functional classification[59]
Provides an easy way to classify patients depending on their physical limitations and has been documented to predict prognosis.[75]
Class I: cardiac disease without limitation of physical activity; ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea
Class II: cardiac disease resulting in slight limitation of physical activity; comfortable at rest; ordinary physical activity results in fatigue, palpitations, or dyspnea
Class III: cardiac disease resulting in marked limitation of physical activity; comfortable at rest; gentle activity causes fatigue, palpitations, or dyspnea
Class IV: cardiac disease resulting in inability to carry out any physical activity without discomfort; symptoms of heart failure at rest; if any physical activity is undertaken, discomfort increases.
Framingham criteria for the diagnosis of congestive HF[76]
The Framingham criteria for the diagnosis of congestive HF were established before the widespread use of echocardiographic assessment of systolic and diastolic dysfunction. The Framingham clinical criteria have been extremely useful for identifying patients with HF, both in clinical practice and in epidemiologic studies, for more than 40 years. However, because their specificity is greater than their sensitivity, it is recognized that they probably miss mild cases of HF. In order to come up with a definite diagnosis of congestive HF, one needs to have either two major criteria or the combination of one major and two minor criteria.
Major criteria:
Neck vein distension
Rales
Acute pulmonary edema
S3 gallop
Increased venous pressure greater than 16 cm of water
Circulation time greater than 25 seconds
Hepatojugular reflux
Cardiomegaly
Paroxysmal nocturnal dyspnea or orthopnea.
Minor criteria:
Ankle edema
Night cough
Dyspnea on exertion
Hepatomegaly
Pleural effusion
Less than one third maximum vital capacity
Tachycardia (heart rate >120 bpm).
Major or minor criteria:
Weight loss greater than 4.5 kg in 5 days in response to treatment.
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