Heart Failure – A Modern Perspective: The International Consensus That’s Changing Diagnosis and Treatment

AUDIO:

Introduction

This material is based on the most recent and comprehensive publication on heart failure: “Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure” (European Journal of Heart Failure, 2021).

The author team includes leading experts from around the world: Prof. Biykem Bozkurt (USA), Prof. Andrew Coats (UK and Australia), Prof. Hiroyuki Tsutsui (Japan), along with over 30 specialists in cardiology, clinical research, and medical education, representing organizations such as the Heart Failure Society of America, the Heart Failure Association of the European Society of Cardiology, the Japanese Heart Failure Society, and others. The publication has been officially endorsed by numerous leading global and regional cardiology societies.

The goal of this article is to present, in plain language, the most important answers to the questions that patients and their families often ask when faced with a heart failure diagnosis—based entirely on this scientific report.

“Heart failure is a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion.”

Expert Insights

Heart failure (HF) is a complex clinical syndrome with major social and medical significance. In recent years, there have been global efforts to standardize the definition and classification of HF—crucial steps for accurate diagnosis, treatment, and patient awareness. Below are five expert and evidence-based insights drawn from the most authoritative international consensus, published in the European Journal of Heart Failure in 2021, designed to help patients and their loved ones better understand the modern approach to this health condition.

1. What exactly is heart failure?

“Heart failure (HF) is a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion.”

Explanation: This definition highlights that HF is not just about a “weak heart.” It’s a syndrome—a combination of symptoms and/or signs (such as shortness of breath, fatigue, swelling)—caused by structural or functional abnormalities in the heart. Diagnosis is confirmed using biomarkers (like natriuretic peptides) and/or imaging or clinical evidence of fluid buildup in the body.

Practical tip: If you suspect HF, ask your doctor to test for natriuretic peptides (BNP or NT-proBNP)—this is the global gold standard!

2. What are the main stages of heart failure?

“We propose revised stages of HF as: At risk for HF (Stage A), Pre-HF (Stage B), Symptomatic HF (Stage C) and Advanced HF (Stage D).”

Explanation: Heart failure is classified into four stages:

• Stage A: People at risk (e.g., with hypertension, diabetes, or coronary disease), but without symptoms or structural heart changes.

• Stage B: No symptoms, but structural or biochemical heart changes are present.

• Stage C: Symptoms of heart failure are already present.

• Stage D: Advanced heart failure requiring specialized treatments, frequent hospitalizations, or even heart transplantation.

Practical tip: If you're diagnosed in an early stage, focus on prevention and early treatment to stop disease progression.

3. What types of heart failure are there based on ejection fraction?

“The classification includes HF with reduced ejection fraction (HFrEF): HF with LVEF ≤40%; HF with mildly reduced ejection fraction (HFmrEF): HF with LVEF 41–49%; HF with preserved ejection fraction (HFpEF): HF with LVEF ≥50%; and HF with improved ejection fraction (HFimpEF): HF with a baseline LVEF ≤40%, a ≥10 point increase from baseline LVEF, and a second measurement of LVEF >40%.”

Explanation: Heart failure is divided by the left ventricular ejection fraction (LVEF), which is measured by echocardiography. This classification guides treatment and prognosis:

• HFrEF: Significantly reduced function (≤40%)

• HFmrEF: Mildly reduced function (41–49%)

• HFpEF: Preserved function (≥50%)

• HFimpEF: Improved function after treatment (≥10-point increase, with LVEF now >40%)

Practical tip: Ask your cardiologist which HF type you have based on your LVEF—this directly impacts the treatment plan.

4. What role do biomarkers play in diagnosis?

“Natriuretic peptides such as B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are elevated in most forms of HF and are an integral component of making a diagnosis of HF in many clinical settings, especially when the diagnosis is uncertain.”

Explanation: Testing for natriuretic peptides is recommended when HF is suspected. High levels of BNP or NT-proBNP suggest HF but must be interpreted carefully, especially in people with kidney disease, obesity, or atrial fibrillation.

Practical tip: Normal values don’t completely rule out HF—especially in HFpEF or overweight patients. A full evaluation by a healthcare professional is essential.

5. What does this mean for non-cardiologists and patients?

“A universal definition of HF is of critical importance to clinicians, investigators, administrators, health care services, institutions, legislators and payers alike... a need for improved communication and understanding of the definition of HF with patients and for shared decision-making and transitions of care between different levels of care and health care professionals.”

Explanation: Experts emphasize that understanding the diagnosis is key—not just for doctors, but for patients and their families. Shared decision-making and clear communication are essential parts of modern care.

Practical tip: Don’t hesitate to ask your doctors questions—being informed and involved in decisions leads to better outcomes and quality of life!

Questions & Answers

1. Can I have heart failure even if I don’t currently have symptoms? 

Answer: Yes, it’s possible. Heart failure can be present without symptoms if there are structural or functional heart changes or elevated levels of natriuretic peptides. This is the so-called "pre-symptomatic" or "Pre-HF" stage (Stage B). There are no complaints yet, but the risk of developing symptoms is higher, so regular monitoring and biomarker testing are important.

2. Can heart failure be mistaken for other conditions? How can I know what’s really causing my symptoms? 

Answer: Yes, many conditions can mimic heart failure symptoms—such as anemia, kidney disease, lung problems, or simply aging. The article stresses that diagnosis should be based not only on symptoms but also on confirmatory tests (biomarkers, echocardiography, etc.). It’s important for doctors to rule out other potential causes to make a reliable diagnosis.

3. Does heart failure always get worse over time, or can it improve? 

Answer: Heart failure is not a static disease—its status can improve or worsen depending on treatment and risk factor control. In some cases, effective therapy can significantly increase the heart’s ejection fraction—this is known as “HF with improved ejection fraction” (HFimpEF). However, deterioration is also possible if treatment is not followed or new problems arise.

4. What biomarkers are important for me, and why can their results sometimes be misleading? 

Answer: The key biomarkers for diagnosing and monitoring heart failure are natriuretic peptides (BNP and NT-proBNP). However, their levels can be influenced by other health conditions (e.g., kidney disease, atrial fibrillation, obesity), as well as age. In some people with HFpEF or obesity, levels may be lower—so the results must always be interpreted by a specialist, not on your own.

5. What are the chances my condition will get worse, and what can I do to prevent that? 

Answer: The risk of heart failure progression depends on many factors—underlying disease, treatment adherence, control of co-existing conditions (like diabetes, high blood pressure, coronary artery disease), and lifestyle. The article notes that even people without symptoms, but with risk factors or structural heart changes, need active monitoring and treatment to prevent worsening heart failure. Prevention and early treatment are key for a better outlook.

Conclusion

The publication by Bozkurt and colleagues represents a global consensus on the definition, classification, and modern management of heart failure. The conclusions are the result of international collaboration among researchers, clinicians, and health organizations from multiple continents and offer the most up-to-date standards for diagnosis, treatment, and patient education.

The trustworthy information provided in this article is meant to help patients and their families understand the disease, take an active role in decision-making, and improve communication with healthcare professionals—leading to better quality of life and treatment outcomes.

Source: Bozkurt B, Coats AJS, Tsutsui H et al. Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure. European Journal of Heart Failure, 2021; 23:352–380. doi:10.1002/ejhf.2115.