Acute Heart Failure: Definition, Classification and Epidemiology

Sameer Kurmani, Iain Squire, Sameer Kurmani, Iain Squire

Abstract

Purpose of review: The purpose of this review is to describe the extent and scope of acute heart failure (AHF), place it within its clinical context and highlight some of the difficulties in defining it as a pathophysiological entity.

Recent findings: A diagnosis of AHF is made when patients present acutely with signs and symptoms of heart failure, often with decompensation of pre-existing cardiomyopathy. The most current guidelines classify based on clinical features at initial presentation and are used to both risk stratify and guide the management of haemodynamic compromise. Despite this, AHF remains a diagnosis with a poor prognosis and there is no therapy proven to have long-term mortality benefits. We provide an introduction to AHF and discuss its definition, causes and precipitants. We also present epidemiological and demographic data to suggest that there is significant patient heterogeneity and that AHF is not a single pathology, but rather a range of pathophysiological entities. This poses a challenge when designing clinical trials and may, at least in part, explain why the results in this area have been largely disappointing.

Keywords: Acute heart failure; Challenges in acute heart failure; Classification of acute heart failure; Decompensated heart failure; Definition of acute heart failure; Epidemiology of acute heart failure.

Conflict of interest statement

Conflict of Interest

Sameer Kurmani and Iain Squire reports personal fees from NOVARTIS.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Figures

Fig. 1
Fig. 1
Stratification of patients admitted with AHF based on initial clinical presentation. Patients may be classified, irrespective of underlying aetiology, according to both their perfusion status (COLD vs WARM) and degree of fluid congestion (WET vs DRY). Based on the initial clinical assessment, prognosis can be determined and an appropriate management strategy put in place. It is important to note that 95% of patients presenting with AHF to the hospital have clinical features of congestion (WET). Adapted from the 2016 ESC guidelines [••]

References

    1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129–2200. doi: 10.1093/eurheartj/ehw128.
    1. National Institute of Clinical Excellence. Chronic heart failure in adults: management 2010. Clinical guideline CG108
    1. Cook C, Cole G, Asaria P, Jabbour R, Francis DP. The annual global economic burden of heart failure. Int J Cardiol. 2014;171(3):368–376. doi: 10.1016/j.ijcard.2013.12.028.
    1. Mosterd A, Hoes AW. Clinical epidemiology of heart failure. Heart. 2007;93(9):1137–1146. doi: 10.1136/hrt.2003.025270.
    1. van Riet EE, Hoes AW, Wagenaar KP, Limburg A, Landman MA, Rutten FH. Epidemiology of heart failure: the prevalence of heart failure and ventricular dysfunction in older adults over time. A systematic review. Eur J Heart Fail. 2016; doi:10.1002/ejhf.483.
    1. Bleumink GS, Knetsch AM, Sturkenboom MC, Straus SM, Hofman A, Deckers JW, et al. Quantifying the heart failure epidemic: prevalence, incidence rate, lifetime risk and prognosis of heart failure: the Rotterdam Study. Eur Heart J. 2004;25(18):1614–1619. doi: 10.1016/j.ehj.2004.06.038.
    1. Donkor A, Cleland J, McDonagh T, Hardman S. National Heart Failure Audit 2016 11.07.2016.
    1. Gheorghiade M, Zannad F, Sopko G, Klein L, Pina IL, Konstam MA, et al. Acute heart failure syndromes: current state and framework for future research. Circulation. 2005;112(25):3958–3968. doi: 10.1161/CIRCULATIONAHA.105.590091.
    1. O’Connor CM, Stough WG, Gallup DS, Hasselblad V, Gheorghiade M. Demographics, clinical characteristics, and outcomes of patients hospitalized for decompensated heart failure: observations from the IMPACT-HF registry. J Card Fail. 2005;11(3):200–205. doi: 10.1016/j.cardfail.2004.08.160.
    1. Nieminen MS, Brutsaert D, Dickstein K, Drexler H, Follath F, Harjola VP, et al. EuroHeart Failure Survey II (EHFS II): a survey on hospitalized acute heart failure patients: description of population. Eur Heart J. 2006;27(22):2725–2736. doi: 10.1093/eurheartj/ehl193.
    1. Fonarow GC, Abraham WT, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, et al. Factors identified as precipitating hospital admissions for heart failure and clinical outcomes: findings from OPTIMIZE-HF. Arch Intern Med. 2008;168(8):847–854. doi: 10.1001/archinte.168.8.847.
    1. Opasich C, Rapezzi C, Lucci D, Gorini M, Pozzar F, Zanelli E, et al. Precipitating factors and decision-making processes of short-term worsening heart failure despite “optimal” treatment (from the IN-CHF Registry) Am J Cardiol. 2001;88(4):382–387. doi: 10.1016/S0002-9149(01)01683-6.
    1. Adams KF, Jr, Fonarow GC, Emerman CL, TH LJ, Costanzo MR, Abraham WT, et al. Characteristics and outcomes of patients hospitalized for heart failure in the United States: rationale, design, and preliminary observations from the first 100,000 cases in the Acute Decompensated Heart Failure National Registry (ADHERE) Am Heart J. 2005;149(2):209–216. doi: 10.1016/j.ahj.2004.08.005.
    1. O’Connor CM, Abraham WT, Albert NM, Clare R, Gattis Stough W, Gheorghiade M, et al. Predictors of mortality after discharge in patients hospitalized with heart failure: an analysis from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) Am Heart J. 2008;156(4):662–673. doi: 10.1016/j.ahj.2008.04.030.
    1. Cleland JG, Swedberg K, Follath F, Komajda M, Cohen-Solal A, Aguilar JC, et al. The EuroHeart Failure survey programme—a survey on the quality of care among patients with heart failure in Europe. Part 1: patient characteristics and diagnosis. Eur Heart J. 2003;24(5):442–463. doi: 10.1016/S0195-668X(02)00823-0.
    1. Komajda M, Follath F, Swedberg K, Cleland J, Aguilar JC, Cohen-Solal A, et al. The EuroHeart Failure Survey programme—a survey on the quality of care among patients with heart failure in Europe. Part 2: treatment. Eur Heart J. 2003;24(5):464–474. doi: 10.1016/S0195-668X(02)00700-5.
    1. Maggioni AP, Dahlstrom U, Filippatos G, Chioncel O, Crespo Leiro M, Drozdz J, et al. EURObservational Research Programme: regional differences and 1-year follow-up results of the Heart Failure Pilot Survey (ESC-HF Pilot) Eur J Heart Fail. 2013;15(7):808–817. doi: 10.1093/eurjhf/hft050.
    1. Follath F, Yilmaz MB, Delgado JF, Parissis JT, Porcher R, Gayat E, et al. Clinical presentation, management and outcomes in the Acute Heart Failure Global Survey of Standard Treatment (ALARM-HF) Intensive Care Med. 2011;37(4):619–626. doi: 10.1007/s00134-010-2113-0.
    1. Abraham WT, Adams KF, Fonarow GC, Costanzo MR, Berkowitz RL, LeJemtel TH, et al. In-hospital mortality in patients with acute decompensated heart failure requiring intravenous vasoactive medications: an analysis from the Acute Decompensated Heart Failure National Registry (ADHERE) J Am Coll Cardiol. 2005;46(1):57–64. doi: 10.1016/j.jacc.2005.03.051.
    1. Abraham WT, Fonarow GC, Albert NM, Stough WG, Gheorghiade M, Greenberg BH, et al. Predictors of in-hospital mortality in patients hospitalized for heart failure: insights from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) J Am Coll Cardiol. 2008;52(5):347–356. doi: 10.1016/j.jacc.2008.04.028.
    1. Ahmed A, Allman RM, Fonarow GC, Love TE, Zannad F, Dell’italia LJ, et al. Incident heart failure hospitalization and subsequent mortality in chronic heart failure: a propensity-matched study. J Card Fail. 2008;14(3):211–218. doi: 10.1016/j.cardfail.2007.12.001.
    1. Yancy CW, Lopatin M, Stevenson LW, De Marco T, Fonarow GC, Committee ASA, et al. Clinical presentation, management, and in-hospital outcomes of patients admitted with acute decompensated heart failure with preserved systolic function: a report from the Acute Decompensated Heart Failure National Registry (ADHERE) Database. J Am Coll Cardiol. 2006;47(1):76–84. doi: 10.1016/j.jacc.2005.09.022.
    1. Ather S, Chan W, Bozkurt B, Aguilar D, Ramasubbu K, Zachariah AA, et al. Impact of noncardiac comorbidities on morbidity and mortality in a predominantly male population with heart failure and preserved versus reduced ejection fraction. J Am Coll Cardiol. 2012;59(11):998–1005. doi: 10.1016/j.jacc.2011.11.040.
    1. O’Connor CM, Miller AB, Blair JE, Konstam MA, Wedge P, Bahit MC, et al. Causes of death and rehospitalization in patients hospitalized with worsening heart failure and reduced left ventricular ejection fraction: results from Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) program. Am Heart J. 2010;159(5):841–9 e1. doi: 10.1016/j.ahj.2010.02.023.
    1. Teerlink JR, Cotter G, Davison BA, Felker GM, Filippatos G, Greenberg BH, et al. Serelaxin, recombinant human relaxin-2, for treatment of acute heart failure (RELAX-AHF): a randomised, placebo-controlled trial. Lancet. 2013;381(9860):29–39. doi: 10.1016/S0140-6736(12)61855-8.
    1. Ponikowski P, Jankowska EA. Pathogenesis and clinical presentation of acute heart failure. Rev Esp Cardiol. 2015;68(4):331–337. doi: 10.1016/j.recesp.2015.01.003.
    1. Nieminen MS, Bohm M, Cowie MR, Drexler H, Filippatos GS, Jondeau G, et al. Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology. Eur Heart J. 2005;26(4):384–416. doi: 10.1093/eurheartj/ehi044.
    1. von Haehling S, Lainscak M, Springer J, Anker SD. Cardiac cachexia: a systematic overview. Pharmacol Ther. 2009;121(3):227–252. doi: 10.1016/j.pharmthera.2008.09.009.
    1. Nohria A, Tsang SW, Fang JC, Lewis EF, Jarcho JA, Mudge GH, et al. Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol. 2003;41(10):1797–1804. doi: 10.1016/S0735-1097(03)00309-7.
    1. Jhund PS, Macintyre K, Simpson CR, Lewsey JD, Stewart S, Redpath A, et al. Long-term trends in first hospitalization for heart failure and subsequent survival between 1986 and 2003: a population study of 5.1 million people. Circulation. 2009;119(4):515–523. doi: 10.1161/CIRCULATIONAHA.108.812172.
    1. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Blaha MJ, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28–e292. doi: 10.1161/01.cir.0000441139.02102.80.
    1. Felker GM, Leimberger JD, Califf RM, Cuffe MS, Massie BM, Adams KF, Jr, et al. Risk stratification after hospitalization for decompensated heart failure. J Card Fail. 2004;10(6):460–466. doi: 10.1016/j.cardfail.2004.02.011.
    1. Diez J. Serelaxin: a novel therapy for acute heart failure with a range of hemodynamic and non-hemodynamic actions. Am J Cardiovasc Drugs. 2014;14(4):275–285. doi: 10.1007/s40256-014-0069-0.
    1. Ramirez A, Abelmann WH. Cardiac decompensation. N Engl J Med. 1974;290(9):499–501. doi: 10.1056/NEJM197402282900906.
    1. Cuffe MS, Califf RM, Adams KF, Jr, Benza R, Bourge R, Colucci WS, et al. Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial. JAMA. 2002;287(12):1541–1547. doi: 10.1001/jama.287.12.1541.
    1. Maisel AS, Peacock WF, McMullin N, Jessie R, Fonarow GC, Wynne J, et al. Timing of immunoreactive B-type natriuretic peptide levels and treatment delay in acute decompensated heart failure: an ADHERE (Acute Decompensated Heart Failure National Registry) analysis. J Am Coll Cardiol. 2008;52(7):534–540. doi: 10.1016/j.jacc.2008.05.010.
    1. Allen LA, Hernandez AF, O’Connor CM, Felker GM. End points for clinical trials in acute heart failure syndromes. J Am Coll Cardiol. 2009;53(24):2248–2258. doi: 10.1016/j.jacc.2008.12.079.
    1. Kelly JP, Mentz RJ, Hasselblad V, Ezekowitz JA, Armstrong PW, Zannad F, et al. Worsening heart failure during hospitalization for acute heart failure: insights from the Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND-HF) Am Heart J. 2015;170(2):298–305. doi: 10.1016/j.ahj.2015.04.007.
    1. • Efficacy, safety and tolerability of serelaxin when added to standard therapy in AHF (RELAX-AHF2). 2017. An example of a randomised controlled trial in acute heart failure which aims to address hard clinical end-points.

Source: PubMed

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