Michael Roscoe is Chair/Program Director and Associate Professor, Andrew Lampkins is Associate Professor, Sean Harper is Assistant Professor, and Gina Niemeier is Associate Program Director and Assistant Professor, in the PA Department at the University of Evansville in Indiana.
The authors have no financial relationships to disclose.
Heart failure is a complex syndrome with a spectrum of signs and symptoms that range from asymptomatic to terminal. This variability of presentation, paired with the irreversibility of the process, make it both difficult and critical to identify this syndrome early to prevent progression. Here is an overview of the classification and common presentations of heart failure, as well as a guide to diagnostic modalities and treatment options.
Heart failure (HF) is a complex syndrome, not a specific disease; it is always associated with an underlying cause. Hypertension and coronary artery disease are the two most common causes in all age groups, but a number of other conditions—valvular disease, unrecognized obstructive sleep apnea, obesity, chronic kidney disease, anemia, hyperlipidemia, diabetes, and atrial fibrillation—have been identified as secondary causes.1-3 To prevent, or at least slow, the development and progression of HF, it is critical to identify (and treat) these comorbidities.
Often, however, clinicians do not identify HF until the syndrome reaches an advanced stage—at which point, the damage is irreversible and pharmacotherapeutic management is limited to control of signs and symptoms. The ramifications are concerning, since HF has achieved near-epidemic scope in the United States. An estimated 5.7 million Americans ages 20 and older have HF; prevalence is projected to increase by 46% between 2012 and 2030—resulting in more than 8 million affected individuals (ages 18 and older).4,5 More than 1 million patients are discharged from the hospital annually with a primary diagnosis of HF.4 And in 2013, one in nine death certificates in the US mentioned HF.4
Most cases of HF are managed in primary care. Established, evidence-based therapies should be implemented in the outpatient setting when possible, as early in the course as possible. Referral to a cardiologist is needed when the underlying cause of HF remains undetermined, or when specialized treatment is required.
CLASSIFICATION OF HF
The two most widely recognized classification systems for HF are those of the American College of Cardiology and the American Heart Association (ACC/AHA) and of the New York Heart Association (NYHA). Both focus on one-year mortality. The stages of the ACC/AHA system (A to D) are based on worsening of both structural heart disease and clinical symptoms of HF. The NYHA designations (Class I to IV) are based on the functional capability associated with physical activity. Both systems are outlined in Table 1.3,6,7
While these systems are used to “stage” HF, there are several ways the syndrome is classified in the medical literature. For example, HF can be described by
Anatomy (left- or right-sided)
Physiology (dilated and hypertrophic)
Course (chronic or acute heart failure [cardiogenic shock])
Output (high- or low-output failure)
Ejection fraction (reduced or preserved)
Pressure phase (systolic and diastolic).
All these classifications have merit; however, this article will attempt to simplify the approach to patients with HF and focus on systolic HF, defined as a reduced left ventricular ejection fraction (LVEF), and diastolic HF, defined as a preserved LVEF. Although the common perception of HF among clinicians—and thus the traditional diagnostic focus—is reduced LVEF (systolic HF), preserved LVEF (diastolic HF) in fact represents approximately 50% of cases.1 Diastolic HF is estimated to be increasing in prevalence and is expected to become the more common phenotype.8
