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Classification of Heart Failure According to Ejection Fraction: JACC Review Topic of the Week
Carolyn S P Lam1, Scott D Solomon2
1National Heart Centre Singapore and Duke-National University of Singapore, Singapore; University Medical Centre Groningen, Groningen, the Netherlands.
Insights
New heart failure classifications emerge following expanded sacubitril/valsartan indications. Patients with mildly reduced ejection fraction may benefit from neurohormonal blockade, with notable sex differences observed.
Area of Science:
- Cardiology
- Pharmacology
Background:
- The U.S. Food and Drug Administration's expanded indication for sacubitril/valsartan impacts heart failure (HF) classification.
- Current HF nomenclature lacks specific categories for ejection fraction (EF) ranges beyond "reduced" and "preserved."
Purpose of the Study:
- To review the evolution of heart failure nomenclature.
- To examine evidence supporting neurohormonal blockade benefits across different ejection fraction ranges.
- To propose a revised nomenclature for heart failure based on ejection fraction.
Main Methods:
- Literature review of heart failure nomenclature and treatment guidelines.
- Analysis of clinical trial data on sacubitril/valsartan and similar therapies.
- Examination of sex-based differences in treatment response.
Main Results:
- Patients with mid-range ejection fraction may benefit from neurohormonal blockade.
- Treatment benefits extend to higher EF ranges in women compared to men.
- Emerging evidence suggests a need for revised HF classification.
Conclusions:
- A proposed nomenclature defines HF with "reduced" (<40%), "mildly reduced," and "normal" (≥55% in men, ≥60% in women) ejection fraction.
- Revised nomenclature can guide therapy selection for a broader HF patient population.
- This classification may improve treatment strategies for patients with mildly reduced ejection fraction.
Abstract:
The recent U.S. Food and Drug Administration expanded indication for sacubitril/valsartan introduces a new potential taxonomy for heart failure, with no reference to "preserved" ejection fraction but referring to "below normal" ejection fraction as those most likely to benefit. This review summarizes the evolution of nomenclature in heart failure and examines evidence showing that patients with ejection fraction in the "mid range" may benefit from neurohormonal blockade similar to those with more severely reduced (<40%) ejection fraction. Furthermore, prominent sex differences have been observed wherein the benefit of neurohormonal blockade appears to extend to a higher ejection fraction range in women compared to men. Based on emerging evidence, revised nomenclature is proposed defining heart failure with "reduced" (<40%), "mildly reduced," and "normal" (≥55% in men, ≥60% in women) ejection fraction. Such nomenclature signals consideration of potentially beneficial therapies in the largest group of patients with reduced or mildly reduced ejection fraction.
