1. The continuous heart failure spectrum: moving beyond an ejection fraction classification
- Author
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Gilles W. De Keulenaer, Robert O. Bonow, Nazha Hamdani, Filippos Triposkiadis, Johann Bauersachs, Richard T. Lee, Vincent F.M. Segers, Ida G. Lunde, Douglas L. Mann, John Parissis, Petros Nihoyannopoulos, Johannes Backs, Alexandre Mebazaa, Vijay K. Chopra, Stephane Heymans, Randall C. Starling, Javed Butler, Ajay M. Shah, Giuseppe M.C. Rosano, Christoph Maack, Alexander R. Lyon, Jean L. Rouleau, Jean Noel Trochu, Wolfgang A. Linke, Zoltán Papp, Rudolf A. de Boer, Marvin A. Konstam, Robert J. Mentz, Thomas Thum, Francois M. Abboud, Petar M. Seferović, Jean-Sébastien Hulot, Carlo G. Tocchetti, Stamatis Adamopoulos, Dirk L. Brutsaert, Faiez Zannad, Gerd Hasenfuss, John Atherton, Leon J. De Windt, Daniel Burkhoff, Paul W. Armstrong, Thierry Pedrazzini, CIC - HEGP (CIC 1418), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpital Européen Georges Pompidou [APHP] (HEGP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), Paris-Centre de Recherche Cardiovasculaire (PARCC (UMR_S 970/ U970)), Hôpital Européen Georges Pompidou [APHP] (HEGP), Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO)-Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Hôpitaux Universitaires Paris Ouest - Hôpitaux Universitaires Île de France Ouest (HUPO)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Paris (UP), Triposkiadis, Filippo, Butler, Javed, Abboud, Francois M, Armstrong, Paul W, Adamopoulos, Stamati, Atherton, John J, Backs, Johanne, Bauersachs, Johann, Burkhoff, Daniel, Bonow, Robert O, Chopra, Vijay K, de Boer, Rudolf A, de Windt, Leon, Hamdani, Nazha, Hasenfuss, Gerd, Heymans, Stephane, Hulot, Jean-Sébastien, Konstam, Marvin, Lee, Richard T, Linke, Wolfgang A, Lunde, Ida G, Lyon, Alexander R, Maack, Christoph, Mann, Douglas L, Mebazaa, Alexandre, Mentz, Robert J, Nihoyannopoulos, Petro, Papp, Zoltan, Parissis, John, Pedrazzini, Thierry, Rosano, Giuseppe, Rouleau, Jean, Seferovic, Petar M, Shah, Ajay M, Starling, Randall C, Tocchetti, Carlo G, Trochu, Jean-Noel, Thum, Thoma, Zannad, Faiez, Brutsaert, Dirk L, Segers, Vincent F, and De Keulenaer, Gilles W
- Subjects
Clinical Review ,Ejection fraction ,Cardiac & Cardiovascular Systems ,[SDV]Life Sciences [q-bio] ,Disease ,Comorbidity ,030204 cardiovascular system & hematology ,EXERCISE CAPACITY ,law.invention ,Ventricular Dysfunction, Left ,0302 clinical medicine ,Randomized controlled trial ,law ,Reference Values ,Medicine ,Myocytes, Cardiac ,030212 general & internal medicine ,1102 Cardiorespiratory Medicine and Haematology ,OUTCOMES ,Ventricular Remodeling ,Stroke volume ,ASSOCIATION ,3. Good health ,PREVALENCE ,VENTRICULAR-FUNCTION ,Cardiology ,Disease Progression ,cardiovascular system ,Cardiology and Cardiovascular Medicine ,ECHOCARDIOGRAPHY ,Life Sciences & Biomedicine ,circulatory and respiratory physiology ,medicine.medical_specialty ,Heart failure ,Pathophysiology ,GLOBAL LONGITUDINAL STRAIN ,03 medical and health sciences ,Internal medicine ,CO-MORBIDITIES ,Humans ,cardiovascular diseases ,Endothelium ,Ventricular remodeling ,Science & Technology ,business.industry ,Stroke Volume ,medicine.disease ,DYSFUNCTION ,COMORBIDITIES ,Cardiovascular System & Hematology ,Cardiovascular System & Cardiology ,Human medicine ,Endothelium, Vascular ,business ,Heart failure with preserved ejection fraction - Abstract
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.
- Published
- 2021