This document defines and discusses different types of heart failure, including heart failure with reduced ejection fraction (HFrEF), heart failure with mildly reduced ejection fraction (HFmrEF), and heart failure with preserved ejection fraction (HFpEF). It outlines diagnostic criteria and pharmacological treatments recommended for each type, including goals of treatment. Advanced heart failure and acute heart failure are also defined.

1. Heart Failure
Evidence Based Management
Ariel Browne

2. Outline
• Definition
• Terminology
• Etiology
• Diagnosis
• Pharmacological treatments
• Advanced Heart failure
• Acute Heart Failure

3. Definition
• Heart failure is not a single pathological diagnosis, but a clinical syndrome
consisting of cardinal symptoms that may be accompanied by signs. It is due to a
structural and/or functional abnormality of the heart that results in elevated
intracardiac pressures and/or inadequate cardiac output at rest and/or during
exercise

4. Classes or recommendations
Levels of evidence

5. Terminology
Heart Failure reduced Ejection Fraction (HFrEF)
• Reduced LVEF is defined as <_40%, i.e. those with a significant
reduction in LV systolic function.
Heart Failure mildly reduced Ejection Faction (HFmrEF)
• Patients with a LVEF between 41% and 49% have mildly reduced
LV systolic function.
Heart Failure with preserved Ejection fraction (HFpEF)
• Patients with a LVEF >_50%

6. New York Heart Association functional
classification based on severity of symptoms and
physical activity

7. Etiology

9. Symptoms
and
Signs of heart
failure

10. Diagnosis

11. Recommended
diagnostic tests in
all patients with
suspected chronic
heart failure

12. Pharmacological treatments
Patients with heart failure with reduced ejection fraction
Goals for treatment;
• Reduction in mortality
• Prevention of recurrent hospitalizations
• Improvement in clinical status, functional capacity and Quality of life

13. Angiotensin-
converting enzyme
inhibitors

15. Beta Blockers

17. mineralocorticoids
antagonist

19. SGLT2 inhibitors

21. Angiotensin
receptor neprilysin
inhibitors

25. Evidence-based
doses of disease-
modifying drugs

26. Other pharmacological
treatments indicated in selected
patients with NYHA class II–IV
heart failure with
reduced ejection fraction (LVEF
40%)

27. Angiotensin II
receptor blockers

32. Cardiac rhythm management
for heart failure with reduced
ejection fraction

34. Cardiac
resynchronization
therapy

36. Heart failure with mildly
reduced ejection fraction
• The diagnosis of HFmrEF requires the presence of symptoms and/or signs of HF,
and a mildly reduced EF (41-49%)
• The presence of elevated NPs and other evidence of structural heart disease
make the diagnosis more likely but are not mandatory for diagnosis if there is
certainty regarding the measurement of LVEF.

37. HFmrEF
EF41-49%

38. Heart failure with preserved
ejection fraction
• Symptoms and signs of HF.
• 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 NPs

39. No treatment has been shown to convincingly reduce mortality and morbidity in
patients with HFpEF
Hospitalizations for HF were
reduced by candesartan and spironolactone and there was a trend
towards reduction with sacubitril/valsartan

40. Recommendations for the treatment of patients with
heart failure with preserved ejection fraction

41. Recommendations
for the primary
prevention of heart
failure in patients
with risk factors for
its development

42. Advanced heart Failure
• Characterized by persistent symptoms despite maximal therapy.
• A severely reduced LVEF is common but not required for a diagnosis of advanced
HF as it may develop in patients with HFpEF as well.

43. Advanced
heart failure
Criteria for definition of
advanced heart failure

45. Acute heart failure
• Refers to rapid or gradual onset of symptoms and/or signs of
HF, severe enough for the patient to seek urgent medical attention,
leading to an unplanned hospital admission or an emergency department visit.

53. References
1. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
[Internet]. Escardio.org. 2022 [cited 16 March 2022]. Available from:
https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-and-Chronic-
Heart-Failure