Uploaded byDuke Heart
Update in HF Definition and Classification: Universal Definition and Stages of HF (UDHF)
1. The document presents an overview of Biykem Bozkurt, an expert in heart failure, and their work updating the definition and classification of heart failure. 2. The Universal Definition of Heart Failure (UDHF) defines heart failure as a clinical syndrome with current or prior symptoms and/or signs caused by structural and/or functional cardiac abnormalities, as corroborated by elevated natriuretic peptide levels or objective evidence of congestion. 3. The UDHF also establishes a classification system with Stages A through D based on risk, presence of structural heart disease, and severity of symptoms, to help guide treatment strategies according to the stage of heart failure.
More Related Content
![Heart failure – an update [autosaved]](https://cdn.slidesharecdn.com/ss_thumbnails/heartfailureanupdateautosaved-110321012825-phpapp02-thumbnail.jpg?width=640&height=640&fit=bounds)
Similar to Update in HF Definition and Classification: Universal Definition and Stages of HF (UDHF)
Update in HF Definition and Classification: Universal Definition and Stages of HF (UDHF)
- 1. Biykem Bozkurt, MDPhD, FHFSA, FACC, FAHA, FESC Associate Provost for Faculty Affairs, Senior Associate Dean for Faculty Development The Mary and Gordon Cain Chair & Professor of Medicine Director, Winters Center for HF Research, Associate Director, Cardiovascular Research Institute Baylor College of Medicine, Houston, TX Medicine Chief, Michael E. DeBakey VA Medical Center Past President, Heart Failure Society of America @BiykemB Update in HF Definition and Classification: Universal Definition and Stages of HF (UDHF) Treatment Implications and Knowledge Gaps
- 2. • Clinical EventCommittee: Abbott, GUIDE HF Trial • Consultation: scPharmaceuticals, Amgen, Vifor, • Relypsa, Respicardia • DSMC: Anthem Trial, Liva Nova Disclosures
- 3. Universal Definition ofHF (UDHF) Chinese Heart Failure Association Bozkurt, et al. Universal Definition and Classification of Heart Failure, Journal of Cardiac Failure, 2021
- 4. Overarching definition EF Phenotype Stages Syndrome dx, Trials, Research Successful GDMT Initiallyto Emphasize Prevention Existing Definitions and Classifications
- 5. “Textbook” definition : “Aclinical syndrome caused by the inability of the heart to meet tissue metabolic requirements” Former Definitions of Heart Failure
- 6. Heart failure isa condition in which the heart can't pump enough blood to meet the body's needs. Circa 1977: “Abnormality of cardiac structure or function leading to failure of the heart to deliver oxygen at a rate commensurate with the requirements of the metabolizing tissues” Wagner S, Cohn K. Heart failure. A proposed definition and classification. Arch Intern Med 1977;137:675–678. Braunwald E. Heart failure. JACC Heart Fail 2013;1:1–20 Francis GS, Wilson Tang WH, Walsh RA. Pathophysiology of heart failure. In: Fuster V, Walsh RA, Harrington RA, eds. Hurst’s The Heart, 13th ed; 2011.pp719–738 Adamo L, Nassif ME, Novak E, LaRue SJ, Mann DL. Prevalence of lactic acidemia in patients with advanced heart failure and depressed cardiac output. Eur J Heart Fail. 2017;19(8):1027‐1033 1 % Few HF Patients Meet the Historical HF Definition:
- 7. HF is asyndrome caused by cardiac dysfunction, generally resulting from myocardial muscle dysfunction or loss and characterized by either LV dilation or hypertrophy or both. Whether the dysfunction is primarily systolic or diastolic or mixed, it leads to neuro-hormonal and circulatory abnormalities, usually resulting in characteristic symptoms such as fluid retention, shortness of breath, and fatigue, especially on exertion. HF is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood HF is a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress. Heart failure is defined as a clinical syndrome consisting of dyspnea, malaise, swelling and/or decreased exercise capacity due to the loss of compensation for cardiac pumping function due to structural and/or functional abnormalities of the heart HF Definition in Guidelines Differed
- 8. ICD-10-CMP I42.9: Cardiomyopathy(familial) (idiopathic) I42.9 secondary I42.9 idiopathic I42.9 primary (idiopathic) I42.9 Myocardiopathy (congestive) (constrictive) (familial) (hypertrophic nonobstructive) (idiopathic) (infiltrative) (obstructive) (restrictive) (sporadic) I42.9 CMP Stage C/D ICD-10-HF I50: Coding guidance states first code following HF complicating abortion or ectopic pregnancy HF due to hypertension (I11.0); HF due to hypertension with CKD (I13.-); rheumatic heart failure (I09.81) HF following surgery I50.2: Systolic (congestive) heart failure I50.4 Combined systolic (congestive) and diastolic (congestive) heart failure No code for at-risk for HF or pre-HF • to capture Stage A /at-risk / preHF prevalence • to treat for specific risk At-risk for HF Stage A Stage B Stage C/ D Chaos in Documentation/Administrative Coding
- 9. 83 79.8 85.1 73.4 66.3 61.7 54 86.2 92.2 67 80.2 81.7 43 34.4 60.3 33.4 33.7 35.7 1313.6 19.8 0 20 40 60 80 100 EuroHeart GDMT Among Indicated % IMPROVE-Baseline GDMT Use % IMPROVE- GDMT Use 24 Months Post Intervention % CHAMP Original-Baseline GDMT Use Among Eligible Patients % CHAMP Longitudinal- Baseline GDMT Use Among Eligible Patients (%) CHAMP Longitudinal- GDMT Use at 12 Months Among Eligible Patients (%) 2001 2009 2009 2017 2017 2017 Prescription Rates for HF Medications in Heart Failure Registries ACEI/ARB BB MRA ARNI Bozkurt B. J Am Coll Cardiol. 2019 May 21;73(19):2384-2387 Failure: Treatment of HF in the Last 2 Decades
- 10. Major Criteria (need1 or more) • Acute pulmonary edema • Cardiomegaly • HJR • JVD • PND/Orthopnea • Rales • S3 Minor Criteria (need 2 or more) • Ankle edema • Dyspnea on exertion • Hepatomegaly • Nocturnal cough • Pleural effusion • Tachycardia (HR > 120) Clinical Trials: Framingham Criteria Episodes of Care: Hospitalization, ER visits Objective Criteria: NP levels
- 11. Other Disease Definitionswith Objective Quantitative Markers • BP consistently higher than 130/80 Hypertension • Fasting glucose ≥126 mg/dL or non-fasting ≥200 mg/dL or Hb A1c ≥6.5% Diabetes • eGFR <60 ml/min/1.73m2 on at least 2 occasions 90 days apart CKD • GOLD grades by FEV1 % predicted thresholds COPD • BMD ≥2.5 SD below the normal mean for young-adult women Osteoporosis:
- 12. European Heart Journal(2021) 42, 2331–2343
- 14. Symptoms and/or signs ofHF caused by a structural and/or functional cardiac abnormality Elevated natriuretic peptide levels Objective evidence of cardiogenic pulmonary or systemic congestion and corroborated by at least one of the following or HF is a clinical syndrome with current or prior • Symptoms and or signs caused by a structural and/or functional cardiac abnormality (as determined by EF<50%, abnormal cardiac chamber enlargement, E/E’ >15, moderate/severe ventricular hypertrophy or moderate/severe valvular obstructive or regurgitant lesion) • and corroborated by at least one of the following: elevated natriuretic peptide levels objective evidence of cardiogenic pulmonary or systemic congestion by diagnostic modalities such as imaging (e.g. by CXR or elevated filling pressures by echocardiography) or hemodynamic measurement (e.g. right heart catheterization, PA catheter) at rest or with provocation (e.g. exercise) Bozkurt, et al. Universal Definition and Classification of Heart Failure, Journal of Cardiac Failure, 2021, ISSN 1071-9164, https://doi.org/10.1016/j.cardfail.2021.01.022. The Universal Definition of HF UDHF)
- 15. Stage A • Athigh risk for HF but without structural heart disease or symptoms of HF Stage B • Structural heart disease but without signs or symptoms of HF Stage C • Structural heart disease with prior or current symptoms of HF Stage D • Refractory HF requiring specialized interventions Yancy CW, et al. Circulation. 2013;128(16):e240-327. ACC/AHA HF Stages
- 16. HEALTHY AT RISK (STAGE A) PRE-HF (STAGEB) Treatment Strategies According to Stages of HF HF (STAGE C) Risk Treatment Primordial Prevention Specific for risk: SGLT2i for DM, ACEi/ARB/ thiazide +LSM for HTN GDMT for LVSD BB, ACEi/ ARB, ICD GDMT for HF: BB, ACEI/ARB, ARNi, MRA, ICD, SGLT2i, Hyd+ISDN Vericiguat Reverse remodeling / neurohormonal antagonism Treatment for symptoms. reverse remodeling / neurohormonal antagonism Specific for etio, risk/ injury/ stretch neurohormonal antagonism Higher Risk Treatment HIGHER RISK PHENOTYPE NT-proBNP microalbumiuria
- 17. Persistent Heart Failure AT-RISK FOR HEARTFAILURE (STAGE A) PRE-HEART FAILURE (STAGE B) HEART FAILURE (STAGE C) ADVANCED HEART FAILURE (STAGE D) Patients with HTN, CVD, DM, obesity, known exposure to cardiotoxins, family history of cardiomyopathy Patients without current or prior symptoms or signs of heart failure but evidence of one of the following Patients at risk for HF but without current or prior symptoms or signs of HF and without structural, biomarker, or genetic markers of heart disease. Structural Heart Disease: e.g. LVH, chamber enlargement, wall motion abnormality, myocardial tissue abnormality, valvular heart disease Abnormal cardiac function: e.g. reduced LV or RV ventricular systolic function, evidence of increased filling pressures or abnormal diastolic dysfunction Elevated natriuretic peptide levels or elevated cardiac troponin levels in the setting of exposure to cardiotoxins Patients with current or prior symptoms and/ or signs of HF caused by Severe symptoms and/ or signs of HF at rest, recurrent hospitalizations despite GDMT, refractory or intolerant to GDMT structural and/or functional cardiac abnormality requiring advanced therapies such as consideration for transplant, mechanical circulatory support, or palliative care with GDMT and risk factor modification Heart Failure in Remission Bozkurt, et al. Universal Definition and Classification of Heart Failure, Journal of Cardiac Failure, 2021, ISSN 1071-9164, https://doi.org/10.1016/j.cardfail.2021.01.022. Universal Definition Stages of HF
- 18. European Heart Journal(2021) 42, 2331–2343
- 19. European Heart Journal(2021) 42, 2331–2343 Asymptomatic+ NP elevation already defined in UDHF =Pre-HF Stage (Stage B)
- 20. New onset/ denovo HF: • Newly diagnosed HF • No former history of HF Worsening HF: • Worsening symptom/signs/ functional capacity, and/or requiring escalation of therapies such as IV or other advanced therapies • and/or hospitalization Improving HF: • Improving symptoms/signs and or functional capacity Persistent HF: • Persistent HF with ongoing symptoms/signs and or limited functional capacity HF in Remission: • Resolution of symptoms and signs of HF, with resolution of previous structural/functional heart disease after a phase of symptomatic HF Do not use “Recovered HF” instead, use “HF in Remission” Do not use “Stable HF”, instead, use “Persistent” Bozkurt, et al. Universal Definition and Classification of Heart Failure, Journal of Cardiac Failure, 2021, ISSN 1071-9164, https://doi.org/10.1016/j.cardfail.2021.01.022. Other Clinical Trajectory Terminologies in HF
- 21. • HF withLVEF ≤ 40% HF with reduced EF (HFrEF): • HF with LVEF 41-49% HF with mildly reduced EF (HFmrEF): • HF with LVEF > 50% HF with preserved EF (HFpEF): • HF with a baseline LVEF ≤ 40%, a ≥ 10 point increase from baseline LVEF, and a second measurement of LVEF > 40% HF with improved EF (HFimpEF): Bozkurt, et al. Universal Definition and Classification of Heart Failure, Journal of Cardiac Failure, 2021, ISSN 1071-9164. EF Classification of HF in Universal Definition
- 22. HFrEF BB ACEi/ARB/ARNi MRASGLT2i Decongest Current Standard Core Medical Therapy STAGE C HFrEF
- 23. Benefit with ARB,MRA, ARNi, SGLT2i in HFrEF & HFmrEF Spironolactone: TOPCAT Solomon et al, 2016 EHJ ARB: CHARM-PRESERVED Lund L et al, EJHF, 2018 ARNI: PARAGON-HF. Solomon et al, Circulation, 2020 EMPEROR PRESERVED and PARAGON Packer Circulation. 2021;143:337–349
- 24. Benefit higher inlower LVEF Bozkurt & Ezekowitz Circulation. 2020;141:362–366. DOI: 10.1161/CIRCULATIONAHA.120.045008
- 25. Anker et alNEJM 2021 DOI: 10.1056/NEJMoa2107038 ~3000 pts NYHA Class II-IV HF, LVEF > 40 % elevated BNP ARNi (sacubitril valsartan) vs valsartan HFpEF: EMPEROR-Preserved Trial HR 0.79 (95% CI 0.69, 0.90) P = 0.0003 Placebo: 511 patients with event Rate: 8.7 per 100 patient-years 20 15 10 5 0 Estimated Cumulative Incidence (%) Placebo Empagliflozin Empagliflozin: 415 patients with event Rate: 6.9 per 100 patient-years NNT=31 RRR 21% During a median trial period of 26 months.
- 26. HR (95% CI) EmpagliflozinPlacebo n with event/N analysed 415/2997 511/2991 0.79 (0.69–0.90) 258/2298 157/699 319/2321 192/670 0.81 (0.68–0.95) 0.73 (0.59–0.90) 157/1079 258/1917 177/1038 334/1953 0.85 (0.69–1.06) 0.75 (0.64–0.89) Overall HF hospitalization in ≤12 months No Yes Cause of HF Ischaemic Non-ischaemic Baseline NYHA class* II III/IV 275/2435 140/562 361/2452 150/539 0.75 (0.64–0.87) 0.86 (0.68–1.09) Baseline LVEF <50% ≥50% to <60% ≥60% 145/995 138/1028 132/974 193/988 173/1030 145/973 0.71 (0.57–0.88) 0.80 (0.64–0.99) 0.87 (0.69–1.10) Baseline NT-proBNP (calculated by AF/flutter status) 126/1477 288/1516 168/1508 341/1476 0.76 (0.61–0.96) 0.78 (0.67–0.91) <Median ≥Median Baseline use of MRA No Yes 233/1878 182/1119 306/1866 205/1125 0.73 (0.62–0.87) 0.87 (0.71–1.06) Baseline use of ACE-inhibitor, ARB or ARNI No 90/569 121/587 Yes 325/2428 *NYHA class I are counted in class II 390/2404 0.75 (0.57–0.99) 0.80 (0.69–0.93) Placebo better Empagliflozin better HR (95% CI) 0.25 0.5 1 2 EMPEROR-Preserved-Primary Endpoint: Effects in Subgroups P-trend = 0.21
- 27. EMPEROR-Preserved: HF TotalHospitalizations
- 28. www.escardio.org/guidelines ©ESC 2021 ESC Guidelinesfor the diagnosis and treatment of acute and chronic heart failure (European Heart Journal 2021 – doi:10.1093/eurheartj/ehab368) Recommendations Class Level Diuretics are recommended in patients with congestion and HFmrEF in order to alleviate symptoms and signs. I C An ACE-I may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death. IIb C An ARB may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death. IIb C A beta-blocker may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death. IIb C An MRA may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death. IIb C Sacubitril/valsartan may be considered for patients with HFmrEF to reduce the risk of HF hospitalization and death. IIb C Pharmacological treatments to be considered in patients with (NYHA class II-IV) heart failure with mildly reduced ejection fraction ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; HF = heart failure; HFmrEF = heart failure with mildly reduced ejection fraction; MRA = mineralocorticoid receptor antagonist; NYHA= New York Heart Association.
- 29. Gaps EF was atool for GDMT Implementation: Limitations Well- Known • Historical trial design: Targeting maladaptive mechanisms associated with phenotypes &severity of HF • Evidence prompted classification HFrEF &HFpEF categories • Evolved as a standardization tool in guidelines for targeting GDMT • With evolving trial results and design changes, now includes HFmrEF • Phenotypic classification, not definition of HF • Normal varies (not only for women vs men, hypertrophy, mitral regurgitation) • Not a reliable tool for phenotypic characterization HFrEF HFmrEF HFprEF
- 30. Gaps Future: EF willevolve into LV Systolic Dysfunction • Benefit signal stronger for LVSD • If widely available, reproducible, practical modalities to detect LVSD • LV global longitudinal strain (or other load independent indices of contractile performance) and maladaptive LV remodeling • LVSD • rEF, mrEF, impEF and/or • Reduced LV strain and/or • LV enlargement : LVESVI, LVEDVI
- 31. ESC 2021 HFGuidelines Harmonized with 2021 Universal Definition www.escardio.org/guidelines ©ESC 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure (European Heart Journal 2021 – doi:10.1093/eurheartj/ehab368) Type of HF HFrEF HFmrEF HFpEF CRITERIA 1 Symptoms ± Signsa Symptoms ± Signsa Symptoms ± Signsa 2 LVEF ≤40% LVEF 41–49%b LVEF ≥50% 3 - - Objective evidence of cardiac structural and/or functional abnormalities consistent with the presence of LV diastolic dysfunction/raised LV filling pressures, including raised natriuretic peptidesc Definition of heart failure with reduced ejection fraction, mildly reduced ejection fraction and preserved ejection fraction HF = heart failure; HFmrEF = heart failure with mildly reduced ejection fraction; HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction; LV = left ventricle; LVEF = left ventricular ejection fraction. aSigns may not be present in the early stages of HF (especially in HFpEF) and in optimally treated patients. bFor the diagnosis of HFmrEF, the presence of other evidence of structural heart disease (e.g. increased left atrial size, LV hypertrophy or echocardiographic measures of impaired LV filling) makes the diagnosis more likely. cFor the diagnosis of HFpEF, the greater the number of abnormalities present, the higher the likelihood of HFpEF.
- 32. HFrEF Stage C- Specific Treatment Modified from Bozkurtet al. Circulation. 2016 Dec 6;134(23):e579-e646 • HTN • Ischemia • Amyloidosis • Valvular Heart disease • Chemotherapy , immunomodulators • COVID-19, Viral • Illicit Drugs / ETOH • Takotsubo/Tachycardia • Metabolic • MINOCA /Microvascul. • RVF, PAH, RV Pacing • Genetic • Peripartum Stage C HFrEF BB ACEi/ARB/ARNi MRA SGLT2i Treat Specific Etiology Diagnose and Treat Specific etiology Maurer et al.N Engl J Med 2018; 379:1007-1016
- 33. Practice Implications First encounter •Diagnose HF: Use UDHF to diagnose, confirm and document HF • Then Classify • EF CLASSIFICATION: to initiate GDMT • STAGES • to initiate appropriate GDMT • for prevention and treatment • prognosis, communication with patient and referral
- 34. Practice Implications Subsequent encounter •HF Trajectory: • Improving: Optimize GDMT • Worsening: Optimize GDMT, consider referral • Persistent (do not use stable HF): Optimize GDMT • In Remission (do not use Recovered HF): Continue GDMT • Reassess classification if symptoms/signs change or indicated for new therapies: • EF re-classification • HFrEF HFrEF, HFmrEF, HFimpEF (not HFpEF or recovered EF) • HFpEFHFrEF, HFmrEF, HpEF • Stages reclassification to determine GDMT prognosis and referral
- 35. Implementation Steps forStandardization in Care Coding and Documentation • ICD codes to harmonize • HF diagnosis • Stages • EF Classifications Registries, administrative databases, research • Reflect new definitions and classifications • Payer /coverage to recognize complexity • Quality measures and performance indicators Timely updates in definitions as concepts and evidence evolve
- 36. Mentz R andLala A. https://doi.org/10.1016/j.cardfail.2021.02.004 New Definition- Stakeholders
- 37. Standardization of HF syndrome definition Symptoms/ signs caused by a structural / functional cardiac abnormality and corroborated by at least one of the following: • elevated NP levels • objective evidence of congestion by diagnostic modalities •to enhance appropriate diagnosis and optimization of GDMT •achieve uniformity of care New revised classification of HF - At Risk for HF, - Pre-HF - HF - Advanced HF Easy to understand by patients and clinicians Clarify treatment indications for pre-HF as well as HF EF Classifications HFrEF: LVEF ≤ 40% HFmrEF : LVEF 41-49% HFpEF: LVEF > 50% HFimpEF: LVEF ≤ 40%, ≥ 10 point , subsequent LVEF>40% Standardization & clarity for treatment indications Emphasis for improved, not recovered EF Trajectories Persistent HF rather than stable HF HF in remission rather than recovered HF Summary: UDHF