Classification of Heart Failure

A panel of medical experts open a discussion surrounding heart failure and its prevalence in health care.

Ryan Haumschild, PharmD, MS, MBA: Hello, and welcome to this AJMC® Peer Exchange program titled, “A Population Health Approach to Managing Heart Failure.” I’m Dr Ryan Haumschild, the director of pharmacy services at Emory Healthcare in the Winship Cancer Institute. Joining me today in this discussion are my colleagues, Dr Jim Januzzi, a cardiologist at the Massachusetts General Hospital and trustee at the American College of Cardiology; Dr Rohit Uppal, the chief clinical officer of hospitalist services at TeamHealth; Dr Jaime Murillo, the senior vice president and chief cardiometabolic health officer at UnitedHealth Group; and Dr John Anderson, practicing internal medicine and diabetes at TriStar Centennial Medical Center. Our panel of experts will explore opportunities for treating heart failure and evaluating the application of the newly updated guidelines. Thank you and let’s begin.

Let’s first start by reviewing the different classifications of heart failure per the updated American College of Cardiology [ACC] guidelines. Let’s discuss some of the key recommendations in the guidelines that are influencing appropriate care. Dr Januzzi, I’d like to start with you. The 2022 ACC guidelines were recently released. Many of us paid attention to them, and we knew that there were some notable updates. Give us some updates of the guidelines and what changed, and discuss some of the pathophysiology of heart failure and the different types of heart failure, such as heart failure with reduced ejection fraction [EF] and heart failure with preserved ejection fraction, so we can have a good baseline as we start this discussion.

Jim Januzzi, MD: Thank you very much for the opportunity to address this important subject. The 2022 ACC/AHA [American Heart Association]/HFSA [Heart Failure Society of America] guideline provides useful information about not only how we should be thinking about heart failure but also how we should be treating it, which is important. Because the approach for treatment is individualized depending on the category of heart failure that a patient is in. People remember the New York Heart Association symptom severity [classification]; that’s a classic way of thinking about heart failure. The problem with the New York Heart Association symptom severity classification is that it only focuses on people with symptoms. It doesn’t tell us about the mechanism of heart failure or address whether a person is at risk for heart failure or has asymptomatic left ventricular dysfunction.

The ACC/AHA/HFSA guidelines provide useful categorization by first focusing on what we refer to as the stages of heart failure. There are stages A, B, C, and D, in which symptomatic heart failure is seen in people who are in stages C and D. But importantly, the guidelines make a clear statement about the importance of recognizing risk and early stages of heart failure and treating those stages in an attempt to prevent progression to symptoms. When a person has symptomatic heart failure, we then start asking, “What’s the mechanism?” The guidelines focus on categorizing patients based on ejection fraction. Individuals who have heart failure with an ejection fraction less than 40% are considered reduced ejection fraction. From an epidemiologic perspective, many of these individuals have coronary artery disease and prior myocardial infarction. There are other causes, including heart muscle disease and valvular heart disease, that may cause reduced ejection fraction.

On the other end of the spectrum, the guidelines talk about individuals who have heart failure with preserved ejection fraction. There’s been a lot of debate about what preserved ejection is, and maybe we can unpack that as we discuss further. But according to the guidelines, preserved ejection fraction is an ejection fraction of 50% or greater. What about the middle? The middle group is something that we’ve started thinking a lot about lately. There are reasons why the ejection fraction of 40% to identify reduced EF came about, and there are reasons why the ejection fraction of 50% or greater came about. But it left this group in the middle with an ejection fraction between 40% and 50% that often were ignored in clinical trials. But that’s no longer the case. This group, also known as heart failure with mildly reduced ejection fraction, has been included in recent clinical trials and are a demographically and epidemiologically distinct population. There are differences between the 3 groups, and their treatments are different as well.

Ryan Haumschild, PharmD, MS, MBA: I like the differentiation you gave. Mildly reduced is very much an emerging treatment area that we should focus on. I’m glad to hear your thoughts on that. Where does the definition around preserved necessarily land? What ejection fraction? How do we be consistent across the different areas? As we know, we have a comorbid patient base, where heart failure continues to grow and we’ve got to treat it more effectively to maintain survival rates and overall survival and reduce mortality.

Transcript edited for clarity.

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