Ejection fraction heart failure stages
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Ejection Fraction and Heart Failure Stages
Universal Definition and Classification of Heart Failure
Heart failure (HF) is a clinical syndrome characterized by symptoms and/or signs caused by structural and/or functional cardiac abnormalities. These abnormalities are often corroborated by elevated natriuretic peptide levels or objective evidence of pulmonary or systemic congestion . The stages of HF have been revised to include:
- Stage A: At risk for HF, but without current or prior symptoms or signs of HF and without structural or biomarker evidence of heart disease.
- Stage B: Pre-HF, with structural heart disease or abnormal cardiac function, or elevated natriuretic peptide levels, but without current or prior symptoms or signs of HF.
- Stage C: Symptomatic HF, with current or prior symptoms and/or signs of HF caused by a structural and/or functional cardiac abnormality.
- Stage D: Advanced HF, with severe symptoms and/or signs of HF at rest, recurrent hospitalizations despite guideline-directed management and therapy (GDMT), and requiring advanced therapies such as transplant or mechanical circulatory support 16.
Ejection Fraction-Based Classification
The classification of HF according to left ventricular ejection fraction (LVEF) includes:
- HF with Reduced Ejection Fraction (HFrEF): Symptomatic HF with LVEF ≤ 40%.
- HF with Mildly Reduced Ejection Fraction (HFmrEF): Symptomatic HF with LVEF 41-49%.
- HF with Preserved Ejection Fraction (HFpEF): Symptomatic HF with LVEF ≥ 50%.
- HF with Improved Ejection Fraction (HFimpEF): Symptomatic HF with a baseline LVEF ≤ 40%, a ≥ 10 point increase from baseline LVEF, and a second measurement of LVEF > 40% 16.
Progression to Advanced Heart Failure
Among patients with Stage C HFrEF, the progression to Stage D HF is a significant concern. A study involving 964 outpatients with Stage C HFrEF found that 4.5% progressed to Stage D HF annually. Factors such as lower ejection fraction, blood pressure, renal and hepatic dysfunction, and chronic lung disease were predictors of progression. Notably, black and nonischemic patients had higher annualized progression rates compared to their counterparts .
Heart Failure with Mid-Range Ejection Fraction (HFmrEF)
HFmrEF, characterized by an LVEF of 41-49%, is a relatively new classification and its nature is still under debate. It may represent a transitional stage between HFrEF and HFpEF rather than a distinct subtype. The complexity and heterogeneity of HFmrEF contribute to inconsistent clinical study results, making it challenging to define uniform treatment and prognosis strategies .
Heart Failure Stages in Older Adults
In older adults, the prevalence of HF stages is significant, with a majority being at risk (Stages A and B). A study of 6118 older adults found that 52% were in Stage A and 30% in Stage B. Notably, left ventricular ejection fraction was preserved in a substantial portion of those with clinical HF (Stages C1 and C2), highlighting the burden of HFpEF in the elderly population .
Predicting Progression in HFpEF
Risk stratification in HFpEF patients can aid in personalized treatment. A multi-parametric evaluation including biomarkers, cardiopulmonary exercise testing, and lung ultrasound has been shown to predict adverse events effectively. This approach can identify HFpEF patients and those at risk (Stages A and B) who are more likely to progress to advanced HF stages .
Temporal Changes in Ejection Fraction
LVEF is not static and can change over time, impacting prognosis. In Stage B patients, LVEF transitions dynamically, with significant prognostic implications. For instance, patients with mid-range or reduced EF at baseline often transition to other EF categories within a year, affecting their clinical outcomes .
Conclusion
Understanding the stages of heart failure and the role of ejection fraction is crucial for effective diagnosis, treatment, and management. The dynamic nature of LVEF and the progression of HF stages underscore the need for continuous monitoring and personalized treatment strategies to improve patient outcomes.
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