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An international committee proposed a universal definition for heart failure (HF) and two standard classifications that go beyond reduced and preserved left ventricular ejection fraction (LVEF).

"HF is a clinical syndrome with symptoms and or signs caused by a structural and or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and or objective evidence of pulmonary or systemic congestion," according to the consensus document from the Heart Failure Society of America (HFSA), European Society of Cardiology, and Japanese Heart Failure Society.

This is a slight difference from the definition of HF from the American College of Cardiology (ACC) and American Heart Association: "a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood."

The universal definition was the work of a writing committee chaired by Biykem Bozkurt, MD, PhD, of DeBakey VA Medical Center and Baylor College of Medicine in Houston. The consensus document was published online in the .

"The release of the Universal Definition and Classification of HF marks an exciting time in the field of HF as we've been burdened with different descriptors that often cause discordance in the HF scientific community, from providers to legislators and everything in between," Bozkurt said in a press release.

"Also, some of the staging terminologies we had used were not clear for our patients, and classifications for EF needed further clarification for the health care professionals," continued Bozkurt, who was immediate past resident of the HFSA.

Four classifications of HF were proposed by Bozkurt's group:

• HF with reduced EF (HFrEF): HF with LVEF 40% or below

• HF with mildly reduced EF (HFmrEF): HF with LVEF 41-49%

• HF with preserved EF (HFpEF): HF with LVEF 50% or above

• HF with improved EF (HFimpEF): HF with baseline LVEF 40% or below that improves by 10 percentage points to a second measurement above 40%

In the past, HF trials have differed in their inclusion criteria by LVEF. For example, PARADIGM-HF required HFrEF patients to have LVEF under 35%, whereas VICTORIA let in people with LVEF under 45%.

The FDA recently declined to set firm LVEF criteria in expanding the indication for sacubitril/valsartan (Entresto) to HFpEF patients.

"Recognition and differentiation of HFmrEF from HFpEF is important in promoting use of therapies such as Entresto in these patients and also would help lower the heterogeneity in patients enrolled in HFpEF trials," commented Ambarish Pandey, MD, of UT Southwestern Medical Center in Dallas.

He said he hoped future trials will stick to the new definition of HFpEF.

With HFimpEF, Bozkurt and colleagues depart from the ACC-preferred terminology of "HF with recovered ejection fraction" (HFrecEF). In addition, HFmrEF is a term that replaces the more common "HF with mid-range EF."

The consensus group kept the staging of HF to span stage A (i.e., person at risk for HF but without symptoms) to stage D (i.e., advanced HF).

Endorsing the new universal definition are the Canadian Heart Failure Society, Heart Failure Association of India, Cardiac Society of Australia and New Zealand, and Chinese Heart Failure Association.

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