New Staging Proposal Highlights Heart Failure as More Preventable, Increasingly Manageable Illness
June 20, 2021
Proposal also notes important role of the heart failure specialist in improving outcomes
Innovations in Cardiovascular Medicine & Surgery | Summer 2021
A new proposed approach to the staging of heart failure (HF) has the potential to improve public knowledge of the condition and to encourage patients to be treated in its earlier stages, when guideline-directed therapy can have the most benefit. It may also lead more patients to seek out the specific expertise of a heart failure specialist. That’s the view of Ravi Ramani, MD, Chief Quality Officer and heart failure specialist at University Hospitals Harrington Heart & Vascular Institute.
Ravi Ramani, MDThe new proposal, published in the Journal of Cardiac Failure and the European Journal of Heart Failure, is endorsed by the Heart Failure Society of America, the Heart Failure Association of the European Society of Cardiology and the Japanese Heart Failure Society, with additional endorsements from the Canadian Heart Failure Society, the Heart Failure Association of India, the Cardiac Society of Australia and New Zealand, and the Chinese Heart Failure Association.
The details of the proposed new approach to staging of HF:
- At-risk for HF (stage A), for patients at risk for HF but without current or prior symptoms or signs of HF and without structural or biomarker evidence of heart disease.
- Pre-HF (stage B), for patients without current or prior symptoms or signs of HF, but evidence of structural heart disease or abnormal cardiac function, or elevated natriuretic peptide levels.
- HF (stage C), for patients with current or prior symptoms and/or signs of HF caused by a structural and/or functional cardiac abnormality.
- Advanced HF (stage D), for patients with severe symptoms and/or signs of HF at rest, recurrent hospitalizations despite guideline-directed management and therapy (GDMT), refractory or intolerant to GDMT, requiring advanced therapies such as consideration for transplant, mechanical circulatory support, or palliative care.
According to Dr. Ramani, this new staging approach will allow for earlier and more data-rich diagnosis of HF, leading to better outcomes for patients.
”For example, with stage B, it doesn't just look at how the heart beats, whether it's stiff or weak,” he says. “It also adds in additional things that can point towards the heart not being normal. Before we would just choose an echocardiogram or an MRI to determine whether something's wrong with the way the heart's beating. This new approach adds other tests, including biomarkers or heart catheterization data, showing that the patient has more fluid than they need to have, even though the patient himself may be asymptomatic. The lack of symptoms remains, but the definition of what is an abnormal heart is expanded.”
The emergence of at-risk and pre-HF categories, similar to pre-cancer of pre-diabetes, may also lead the general public to consider HF as more of a preventable condition or one more effectively managed through early detection, Dr. Ramani says.
“I think that's a great analogy,” he says. “With a pre-heart failure situation, in the majority of cases, the risk factors are modifiable through good clinical follow-up and appropriate medical therapy.”
For other patients, the new proposed staging system will allow heart failure specialists to keep patients in the lowest stage as long as possible, he says, helping to prevent progression from stage B to stage C, or sometimes even reversing from stage D to stage C.
As this new proposal is being discussed, Dr. Ramani says he’s pleased by the attention it has placed on the important role of the heart failure specialist. He says he hopes it will lead to him seeing more patients earlier in the HF disease process, when aggressive guideline-directed medical therapy directed by a heart failure specialist can make the most difference.
“Often times, we get patients referred when they're in extremis,” he says. “They’re really, really sick. However, with good medical therapy, a lot of the comorbid conditions, particularly things like frailty and renal dysfunction are often reversible. If we can catch the patient early on, we can deal with their complex medical issues, make the appropriate referrals and get them what they need.”