Heart Failure – Universal Definition

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The Universal Definition and Classification of Heart Failure is a consensus statement released in 2021. The goal was to provide a standard definition of heart failure to decrease the variability in diagnosis and to better assess the impact of treatment.

Universal Heart Failure Definition: Heart failure is a clinical syndrome with current or prior:

  • Symptoms and/or signs caused by structural and/or functional cardiac abnormality with at least one of the following:
    • EF < 50%
    • Abnormal cardiac chamber enlargement
    • E/E’ of > 15
      • E/E’ is a noninvasive measure of elevated LV filling pressures reported on an echocardiogram
    • Moderate/severe ventricular hypertrophy or moderate/severe valvular obstruction or regurgitant lesion

AND at least one of the following:

  • Elevated natriuretic peptide levels
  • Objective evidence of cardiogenic pulmonary or systemic congestion by diagnostic modalities
    • CXR
    • Elevated filling pressures by echocardiography
    • Hemodynamic measurement
      • R heart catheterization
      • Pulmonary artery catheter

Symptoms of Heart Failure

Typical Less Typical
Breathlessness Nocturnal cough
Orthopnea Wheezing
Paroxysmal nocturnal dyspnea Bloated feeling
Reduce exercise tolerance Postprandial satiety
Fatigue, tiredness Loss of appetite
Ankle swelling Decline in cognitive function, confusion (especially in the elderly)
Inability to exercise Depression
Swelling of parts of the body other than ankles Dizziness, syncope

Signs of Heart Failure

More Specific Less Specific
Elevated jugular venous pressure Peripheral edema
Third heart sound Pulmonary rales
Summation gallop with third and fourth heart sounds Unintentional weight loss
Cardiomegaly, laterally displaced apical impulse Weight loss with muscle wasting and cachexia
Hepatojugular reflux Cardiac murmur
Cheyne Stokes respiration in advanced HF Reduced air entry and dullness to percussion at lung bases suggestive of pleural effusion
Tachycardia, irregular pulse
Cold extremities
Narrow pulse pressure

When diagnosing heart failure, the type of heart failure should be documented. The Universal Definition and Classification of Heart Failure recommends the following classification:

  • HFrEF (HF with reduced ejection fraction)
    • Symptomatic HF with LVEF ≤40%
  • HFmrEF (HF with mildly reduced ejection fraction)
    • Symptomatic HF with LVEF 41-49%
    • Previously labeled as HF with mid-range ejection fraction
  • HFpEF (HF with preserved ejection fraction)
    • Symptomatic HF with LVEF ≥50%
  • HFimpEF (HF with improved ejection fraction) – new classification
    • Must meet ALL 3 criteria
      • Baseline LVEF ≤ 40%
      • ≥ 10-point increase from baseline LVEF
      • A second measurement of LVEF > 40%

Download the complete tip, Universal Definition of Heart Failure.