The continuous heart failure spectrum: moving beyond an ejection fraction classification.


Journal Article

Randomized clinical trials initially used heart failure (HF) patients with low left ventricular ejection fraction (LVEF) to select study populations with high risk to enhance statistical power. However, this use of LVEF in clinical trials has led to oversimplification of the scientific view of a complex syndrome. Descriptive terms such as 'HFrEF' (HF with reduced LVEF), 'HFpEF' (HF with preserved LVEF), and more recently 'HFmrEF' (HF with mid-range LVEF), assigned on arbitrary LVEF cut-off points, have gradually arisen as separate diseases, implying distinct pathophysiologies. In this article, based on pathophysiological reasoning, we challenge the paradigm of classifying HF according to LVEF. Instead, we propose that HF is a heterogeneous syndrome in which disease progression is associated with a dynamic evolution of functional and structural changes leading to unique disease trajectories creating a spectrum of phenotypes with overlapping and distinct characteristics. Moreover, we argue that by recognizing the spectral nature of the disease a novel stratification will arise from new technologies and scientific insights that will shape the design of future trials based on deeper understanding beyond the LVEF construct alone.

Full Text

Duke Authors

Cited Authors

  • Triposkiadis, F; Butler, J; Abboud, FM; Armstrong, PW; Adamopoulos, S; Atherton, JJ; Backs, J; Bauersachs, J; Burkhoff, D; Bonow, RO; Chopra, VK; de Boer, RA; de Windt, L; Hamdani, N; Hasenfuss, G; Heymans, S; Hulot, J-S; Konstam, M; Lee, RT; Linke, WA; Lunde, IG; Lyon, AR; Maack, C; Mann, DL; Mebazaa, A; Mentz, RJ; Nihoyannopoulos, P; Papp, Z; Parissis, J; Pedrazzini, T; Rosano, G; Rouleau, J; Seferovic, PM; Shah, AM; Starling, RC; Tocchetti, CG; Trochu, J-N; Thum, T; Zannad, F; Brutsaert, DL; Segers, VF; De Keulenaer, GW

Published Date

  • July 1, 2019

Published In

Volume / Issue

  • 40 / 26

Start / End Page

  • 2155 - 2163

PubMed ID

  • 30957868

Pubmed Central ID

  • 30957868

Electronic International Standard Serial Number (EISSN)

  • 1522-9645

Digital Object Identifier (DOI)

  • 10.1093/eurheartj/ehz158


  • eng

Conference Location

  • England