Understanding and identifying risk factors, comorbid conditions, and current pharmacotherapeutic options can help clinicians al- leviate the financial burden and reduce the risk of HF.
Healthcare Professional Consideration: Certain age, gender, and ethnicities are more affected by heart failure. Implicit bias towards certain groups of patients may be one of many factors contributing to healthcare disparities. Clinicians should recog- nize at risk groups to promote better health outcomes. This can be achieved by engaging in clear, patient-centered conversa- tions that promotes dialog without perceived bias. Empowering patients though discussions of all treatment options, regardless of demographics or socioeconomic status is imperative for bet- ter outcomes. as systolic HF, HFrEF is the inability of the left ventricle to con- tract sufficiently and is defined by having a left ventricular ejection fraction (LVEF) of 40% or less (Bozkurt et al., 2021). Conversely, HFpEF, or diastolic HF, is the inability of the left ventricle to relax and fill with blood adequately. Representing half of all HF-related hospitalizations, HFpEF is defined as an LVEF of 50% or more and still having signs and symptoms similar to HFrEF. Within the next decade, HFpEF is projected to be the leading subtype of HF (Sharma et al., 2020). Approximately, 13 to 24% of patients with HF have heart failure with mid-range ejection fraction (HFmrEF), defined as an LVEF 41 to 49%, that could progress into either HFpEF or HFrEF (Baliga, 2017). return to a previous stage. Therefore, clinicians should focus on preventive strategies to reduce risk factors at Stage A and imple- ment pharmacotherapy treatment strategies that reduce morbid- ity and mortality beginning at stage C. Meanwhile, the NYHA functional scale subjectively designates limitations in physical activity as HF progresses. Unique to the NYHA scale is the abil- ity to independently predict mortality with each worsening class (Briongos-Figuero et al., 2019).
Definitions As defined by the American College of Cardiology (ACC) and the American Heart Association (AHA), HF is a clinical syndrome resulting from a functional or structural impairment in filling of ventricles or ejection of blood (Bozkurt et al., 2021; Gibson et al., 2021). This cardiac abnormality causes a reduced cardiac output to adequately meet the body’s oxygen demands during rest or physical exertion. As HF progresses, clinical signs (e.g., edema, increased jugular venous pressure, and rales) and symptoms (e.g., dyspnea, fatigue, fluid retention, and orthopnea) may manifest (Bozkurt et al., 2021). The two main subtypes classify heart fail- ure: heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Also referred to Classification of heart failure Two different scales exist to help clinicians classify the presence and severity of HF: the ACC/AHA Staging System and the New York Heart Association (NYHA) functional scale (See Table 1). Al- though complementary, the two scales provide different function- ality. The ACC/AHA Staging System describes the progression of patients in a unidirectional manner based on the presence of symptoms and cardiac structure abnormalities. This stepped ap- proach means that patients with HF may progress from Stage A (at risk of HF development) to Stage D (end-stage HF) but cannot
Table 1: ACC/AHA Staging System and NYHA Functional Classification ACC/AHA Stage Recommendation*(COR/LOE)
NYHA Functional Class
Stage A: Patients at risk of HF (e.g., metabolic syndrome, HTN, or T2DM) with no HF symptoms nor cardiac structural abnormalities. Stage B: Patients with cardiac structural abnormalities but no HF symptoms (e.g., valvular disease). Stage C: Patients with cardiac structural abnormalities and previous or present HF symptoms.
Implement lifestyle modifications Control Risk factors: HTN, T2DM, HLD (I/A) Use natriuretic peptide biomarkers for HF diagnosis, prognosis, and disease severity (I/A) Prevent symptomatic HF with ACEI/ARB if a recent history of ACS or MI (I/A), statin (I/A), BB (I/B) Control Blood pressure to prevent HF (I/A) HFpEF: Add ACEI/ARB (I/A) or ARNI (1/B) with a BB for treatment to reduce morbidity and mortality HFpEF: Control comorbidities (HTN I/B) and symptom management (diuretics (I/C)
No corresponding functional class
Class I: No limitations or symptoms of HF in physical activity.
Class II: Marginal limitation of physical activity Class III: Severe limitation of physical activity Class IV: Unable to perform any physical activity. Symptoms at rest.
Stage D: Patients from Stage C, but no relief from treatment interventions Receive inotropic support until definitive therapy is available (I/C) Cardiac transplantation evaluation (I/C) Note . Stage, recommendation, and NYHA functional class from: 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure, by C.W. Yancy, M Jessup, B Bozkurt, et al. JACC, 70(6), 776-803. Note . ACEI= Angiotensin Converting Enzyme; ACS=Acute Coronary Syndrome; ARB= Angiotensin Receptor Blocker; BB= Beta-Blocker; HLD=Hyperlipidemia; HTN=Hypertension; MI= Myocardial Infarction; T2DM= Type 2 Diabetes Mellitus *Not a complete list of recommendations. Please refer to guidelines for further information Etiology
Historically, coronary artery disease has been the primary cause of HF. According to data from an analysis of the PARADIGM-HF trial, non-ischemic cardiomyopathy (e.g., valvular heart disease,
hypertension, dilated cardiomyopathy, or arrhythmias) represents approximately 40% of the cases of HF (Balmforth et al., 2019). Other less common non-ischemic causes of HF may include iat-
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