Back to the basics: The need for an etiological classification of chronic heart failure

Area of Science:

• Cardiology
• Heart Failure Research
• Clinical Medicine

Background:

• The left ventricular ejection fraction (LVEF) has long been central to heart failure (HF) classification and management.
• This classification has been favored because it identifies patient groups benefiting from specific treatments.

Purpose of the Study:

• To review evidence challenging the utility of LVEF in HF classification.
• To advocate for a shift towards contemporary concepts in guiding chronic HF treatment.

Main Methods:

• Review of current evidence regarding LVEF in HF classification and treatment guidance.
• Analysis of the limitations of LVEF in guiding medical, device, and mechanical circulatory support therapies.
• Proposal of an alternative etiologic HF classification.

Main Results:

• The rationale for LVEF-based HF classification has weakened, as neurohormonal inhibitors benefit most HF patients irrespective of LVEF.
• LVEF is a poor predictor for device therapies like implantable cardioverter-defibrillators and cardiac resynchronization therapy.
• LVEF is an inadequate surrogate for LV size in LV assist device implantation.

Conclusions:

• The reliance on LVEF for HF classification and treatment guidance is increasingly untenable.
• A transition to etiologic HF classification, based on epidemiological data, is proposed.
• This new classification will support higher-resolution phenotyping for precision medicine in HF.