Who Would Be Branded With Failure?

Lynne Warner Stevenson, MD


Circulation. 2017;136(15):1359-1361. 

In This Article

Elongation of the HF Journey

In the early era, most patients presented with class IV symptoms and died of pump failure or sudden death within a year without transplantation. All HF was assumed to be low-ejection-fraction HF, with congestion and hypoperfusion inseparable and inevitable. When therapy was limited to digitalis and diuretics to treat symptoms, it was sufficient to classify HF by the New York Heart Association rating of symptom severity.

The pivotal studies of SAVE (Survival and Ventricular Enlargement Trial) of patients after infarction[2] and SOLVD (Studies of Left Ventricular Dysfunction)[3] of asymptomatic patients showed us that we could inhibit the renin-angiotensin system to reduce the progression to HF, even before the typical HF syndrome. The need then arose to identify structural heart disease before HF symptoms, which led to the stage B designation from the 2005 American Heart Association/American College of Cardiology guidelines. This staging system further targeted disease progression by recommending continued therapy for stage C regardless of current symptoms. Since then, the concept of inexorable progression has been challenged by more potent and durable interventions to change the natural history of HF. We now follow many stage B patients who have not progressed. Some HF clinics report almost a third of their patients as "HF better ejection fraction," previously symptomatic patients with an ejection fraction that has improved from <0.30 to >0.40 to 0.50[4] with parallel symptom improvement, often to class I. Some patients have symptomatic improvement to class I without an improved ejection fraction. Even with some limitation of activity, many patients who adhere to guideline-directed medical therapies and partner in their own fluid management can enjoy a long stable period with good quality of life.