Heart failure classification in clinical practice: time to redefine?

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Heart failure classification in clinical practice: time to redefine?

Kai Hu, Georg Ertl, Stefan Frantz, and Peter Nordbeck from the Comprehensive Heart Failure Center and Department of Internal Medicine I at University Hospital Würzburg, Germany, argue that how we classify heart failure (HF) needs an update to better guide treatment for millions of patients worldwide.

Heart failure is a leading cause of repeated hospital stays, disability, and death globally—even with today’s best treatments. It also strains healthcare systems: in the U.S. alone, HF costs over $30 billion annually, and those numbers are rising as populations age. But one of the biggest challenges in managing HF is how we define and categorize it—and whether those definitions match the complex reality of the disease.

How we classify heart failure today

For years, doctors have used two main systems to describe HF:

  1. Left ventricular ejection fraction (LVEF): This measures how much blood the heart’s main pumping chamber (left ventricle) ejects with each beat. Patients are grouped into three categories:
    • HFrEF (reduced EF): EF ≤40% (the heart doesn’t pump enough blood).
    • HFmrEF (mid-range EF): EF 41–49% (mildly reduced pumping).
    • HFpEF (preserved EF): EF ≥50% (the heart pumps well but doesn’t fill with enough blood).
  2. NYHA class: This rates symptom severity from 1 (mild fatigue with heavy exercise) to 4 (severe shortness of breath at rest).

In 2021, a global group of heart failure societies (including the American and European Heart Failure Societies) proposed a universal definition of HF: a clinical syndrome caused by structural or functional heart problems, confirmed by high levels of “stress hormones” (natriuretic peptides) or signs of fluid buildup (like swollen legs or lung congestion). This definition also stages HF from “at-risk” (Stage A, e.g., high blood pressure) to “advanced” (Stage D, e.g., needing a heart pump).

The problem: One-size-fits-all treatments don’t work for HFpEF

Here’s the catch: Only HFrEF has strong evidence from clinical trials to back guideline-recommended treatments (like ACE inhibitors or beta-blockers). For HFpEF—which affects about half of all HF patients—treatments have been hit-or-miss. Why? HFpEF isn’t a single disease: it can be caused by vascular disease, kidney problems, lung disease, or heart valve issues.

Recent trials offer hope but highlight these challenges:

  • PARAGON-HF trial (2020): The drug sacubitril/valsartan (used for HFrEF) didn’t reduce hospital stays or death for all HFpEF patients. But women and those with EF ≤57% (slightly lower than the “preserved” cutoff) saw benefits.
  • EMPEROR-Preserved trial (2021): The diabetes drug empagliflozin became the first treatment to cut the risk of death or HF hospitalizations for HFpEF. This was a breakthrough—but it still doesn’t work for everyone.

A better way: Etiology-based classification

The root of the problem is that HFpEF’s multiple causes mean “one-size-fits-all” treatments fail. To fix this, researchers like Dr. Ge Jun have proposed etiology-based coding for HFpEF, splitting patients into five groups based on the cause of their HF:

  1. HFpEF-1: Vascular (e.g., high blood pressure damaging blood vessels).
  2. HFpEF-2: Cardiomyopathy (e.g., thickened heart muscle).
  3. HFpEF-3: Right heart/pulmonary (e.g., lung disease straining the right heart).
  4. HFpEF-4: Valvular/rhythm (e.g., leaky valve or irregular heartbeat).
  5. HFpEF-5: Extracardiac (e.g., kidney disease or obesity).

The idea is simple: Treat the cause, not just the symptom. A patient with HFpEF from a leaky valve (HFpEF-4) would benefit more from valve repair than a drug for HFrEF.

ESN-HF: A multifaceted solution for all HF

The Würzburg team builds on this idea with a new classification system called ESN-HF (Etiology-Systolic function-NYHA classification Heart Failure). It combines three critical pieces of information:

  1. Etiology (I–V): The underlying cause of HF (e.g., vascular, cardiomyopathy).
  2. Ejection fraction (A–D): Preserved (pEF), mid-range (mrEF), reduced (rEF), or improved (impEF—when EF gets better over time).
  3. NYHA class (1–4): Symptom severity.

For example:

  • A patient with vascular-related HF, preserved EF, and mild symptoms = I-A-1.
  • A patient with cardiomyopathy, reduced EF, and severe symptoms = II-C-4.

This system captures the full complexity of HF—why it happens, how well the heart works, and how it affects daily life—in a single, easy-to-use code.

Why this matters for patients

Heart failure is a systemic syndrome, not just a “heart problem.” Today’s classifications focus too much on how well the heart pumps and not enough on why it’s failing. A multifaceted system like ESN-HF could:

  • Improve diagnosis accuracy.
  • Help doctors choose treatments tailored to the cause (e.g., blood pressure drugs for vascular HF, valve surgery for valvular HF).
  • Simplify risk stratification (who is most likely to be hospitalized or die).

The road ahead

The authors stress that ESN-HF is a proposal—not a final solution. More research is needed to test whether this system actually improves patient outcomes. But the core idea is clear: To beat HF, we need classifications that reflect its complexity.

As the global burden of HF grows, redefining how we categorize the disease isn’t just an academic exercise—it’s a step toward better care for millions.

References

  1. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics-2016 update: a report From the American Heart Association. Circulation 2016;133:e38–e360. doi.org/10.1161/CIR.0000000000000350
  2. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2016;37:2129–2200. doi.org/10.1093/eurheartj/ehw128
  3. Iyngkaran P, Liew D, Neil C, et al. Moving from heart failure guidelines to clinical practice: gaps contributing to readmissions in patients with multiple comorbidities and older age. Clin Med Insights Cardiol 2018;12:1–13. doi.org/10.1177/1179546818809358
  4. Bozkurt B, Coats AJS, Tsutsui H, et al. Universal definition and classification of heart failure. Eur J Heart Fail 2021;23:352–380. doi.org/10.1002/ejhf.2115
  5. Solomon SD, McMurray JJV. PARAGON-HF Steering Committee and Investigators. Angiotensin-neprilysin inhibition in heart failure with preserved ejection fraction. Reply. N Engl J Med 2020;382:1182–1183. doi.org/10.1056/NEJMc2000284
  6. Breakthrough Results for Jardiance (empagliflozin) confirm EMPEROR-Preserved as first and only successful trial for heart failure with preserved ejection fraction. Boehringer Ingelheim GmbH 2021. boehringer-ingelheim.us/press-release/breakthrough-results-jardiance-empagliflozin-confirm-emperor-preserved-first-and-only
  7. Ge J. Coding proposal on phenotyping heart failure with preserved ejection fraction: a practical tool for facilitating etiology-oriented therapy. Cardiol J 2020;27:97–98. doi.org/10.5603/CJ.2020.0023
  8. Hu K, Ertl G, Frantz S, Nordbeck P. Heart failure classification in clinical practice: time to redefine?. Chin Med J 2022;135:1039–1040. doi.org/10.1097/CM9.0000000000001823

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