Universal Classification of Heart Failure

James Januzzi, MD: We’ve jumped ahead a little bit, but you heard Dr Vaduganathan mention ejection fraction. Rob, there have been some recent developments in the classification of how we think about heart failure, and for the viewers it would be helpful , to go through with the universal definition and classification, in particular how we classify heart failure these days?

Robert J. Mentz, MD: This is a really important piece so that we can level the playing field, and I’ll be speaking with the same term. As we think of the different phenotypes or groups of patients with heart failure, there is that heart failure with reduced ejection fraction, or HFrEF, with that ejection fraction commonly assessed on echo [echocardiography] or maybe MRI [magnetic resonance imaging], but it’s 40% or less, so that’s that 1 group. Then there’s this mildly reduced. Using that language, so we’re all being consistent, so that’s the 41 to 49%, EF [ejection fraction] group, and then importantly that third group, which we know is even increasing more in terms of incidence and prevalence moving forward. So that’s 50% or higher. Consistently using these terms will help us be clear as we speak to our patients, their families and work to get patients on the right medications.

James Januzzi, MD: That’s terrific, and we’re going to get into the therapeutics, but I think it’s helpful for Dr Butler to give us a high level summary from a therapeutic perspective, how do we tend to group these patients? How are the studies that develop these therapies perform? To some extent we’re going to see those barriers disappearing more and more, but presently do you think of patients with reduced EF any differently than say, mildly reduced or preserved in terms of how you study them in the trials that you did?

Javed Butler, MD, MPH, MBA: Our thought process around this is clearly evolving. Historically we have done trials in patients with heart failure and reduced ejection fraction those with 40% or less, and heart failure with preserved ejection fraction as EF greater than 40%. A lot of the observational data and EpiData would suggest that the patients with mildly reduced ejection fraction pretty much act like heart failure with reduced ejection fraction and therefore they are now actually called heart failure with mild reduced ejection fraction. If you look at the benefit with therapy, they are pretty comparable in reduced and mildly reduced. It turns out that less than 50%, you f have this homogenous group, although it is classified a little bit differently. Now the HFpEF which is greater than 50%, actually many of the therapies that work in heart failure with reduced or mildly reduced ejection fraction, tend to benefit those with HFpEF as well, but that’s where a little bit of nuance comes in, and we can discuss that, that whether they work across the entire spectrum or up to 60%, 65%. I’m sure we’ll get into those details, but these concepts are evolving.

James Januzzi, MD: It really speaks to how the therapies were developed, to some extent the therapeutics for reduced EF where we were successful quickly in finding therapies were based on individuals with EF less than 40%, but the truth of the matter is, ejection fraction is a derived variable, and it doesn’t speak to the biology in a lot of these patients.

Javed Butler, MD, MPH, MBA: Not only that, we sometimes forget that historically the reason why we came up with this disease called heart failure with reduced ejection fraction was not based on any pathophysiologic consideration, it was an inclusion criteria for clinical trials so that we can enrich high risk populations. It took us a little bit of time, but we are learning more and thinking about the disease differently.

James Januzzi, MD: Super. Rob, since you brought up the different categories, are there major differences in let’s say the socioeconomic picture, ethnicity, race, medical conditions, etc, between the various groups?

Robert J. Mentz, MD: This is a really important piece as we start to think how can we best identify and manage our patients with heart failure across this EF spectrum as Javed has just gone through. Certainly in that heart failure with preserved ejection fraction group, it tends to be individuals that are older, we do see more commonly in women, those with comorbidities like diabetes and obesity. Realizing that importantly across the spectrum we can see younger patients with HFpEF as well. We need to make sure we’re not missing a diagnosis for these individuals, and we’ll get into some of the specifics of the universal definition and how that leads and supports our diagnosis. Then realizing that there are disadvantaged groups, so there’s delays to the treatment of coronary disease in certain populations, Hispanic individuals, black individuals. We must make sure that we’re identifying the disease in those patients, getting on the right therapies and having a multidisciplinary team managing their clinical course and making sure we can help then with all of these.

James Januzzi, MD: That’s very important for the optimal management of these patients as team-based care, and we will have a good opportunity to discuss further how we each individually do this, because it’ll help the viewers understand that it’s not a one-person show by any stretch.

Transcript edited for clarity