Elsevier

The Lancet

Volume 390, Issue 10106, 28 Octoberā€“3 November 2017, Pages 1981-1995
The Lancet

Seminar
Heart failure

https://doi.org/10.1016/S0140-6736(17)31071-1Get rights and content

Summary

Heart failure is common in adults, accounting for substantial morbidity and mortality worldwide. Its prevalence is increasing because of ageing of the population and improved treatment of acute cardiovascular events, despite the efficacy of many therapies for patients with heart failure with reduced ejection fraction, such as angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), Ī² blockers, and mineralocorticoid receptor antagonists, and advanced device therapies. Combined angiotensin receptor blocker neprilysin inhibitors (ARNIs) have been associated with improvements in hospital admissions and mortality from heart failure compared with enalapril, and guidelines now recommend substitution of ACE inhibitors or ARBs with ARNIs in appropriate patients. Improved safety of left ventricular assist devices means that these are becoming more commonly used in patients with severe symptoms. Antidiabetic therapies might further improve outcomes in patients with heart failure. New drugs with novel mechanisms of action, such as cardiac myosin activators, are under investigation for patients with heart failure with reduced left ventricular ejection fraction. Heart failure with preserved ejection fraction is a heterogeneous disorder that remains incompletely understood and will continue to increase in prevalence with the ageing population. Although some data suggest that spironolactone might improve outcomes in these patients, no therapy has conclusively shown a significant effect. Hopefully, future studies will address these unmet needs for patients with heart failure. Admissions for acute heart failure continue to increase but, to date, no new therapies have improved clinical outcomes.

Introduction

Heart failure is a syndrome characterised by symptoms (such as breathlessness, ankle swelling, and fatigue) and signs (eg, raised jugular venous pressure, pulmonary crackles, and peripheral oedema) caused by structural or functional cardiac abnormalities that lead to elevated intracardiac pressures or a reduced cardiac output at rest or during stress. Heart failure is a leading and increasing cause of morbidity and mortality worldwide. General physicians and family doctors, and emergency physicians in cases of acute heart failure, care for most patients with heart failure.

Section snippets

Classification

Many clinical classification systems have been used for heart failure, including those based on symptom severityā€”eg, as assessed by the New York Heart Association functional classification system1ā€”or on disease progression, as staged from A to D in the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines.2 The ACC/AHA guidelines include patients at risk of developing heart failure (stage A) and those with structural heart disease but without signs and symptoms

Epidemiology

Chronic heart failure affects about 2% of the adult population worldwide. The prevalence of heart failure is age-dependent, ranging from less than 2% of people younger than 60 years to more than 10% of those older than 75 years.9, 10, 11, 12 Increased values are found when the definition incorporates patients with asymptomatic left ventricular dysfunction, including an increase to 5Ā·5% in people 60 years or older with systolic dysfunction and an increase to 36Ā·0% in people 60 years or older

Definition

Acute heart failure is increasingly recognised as a distinct disorder with unique pathophysiology, treatments, and outcomes. Acute heart failure can be defined as the new onset or recurrence of symptoms and signs of heart failure, requiring urgent evaluation and treatment and resulting in unscheduled care or hospital admission.1, 111 Although the word acute suggests a sudden onset of symptoms, many patients might have a more subacute course, with gradual worsening of symptoms that ultimately

Conclusions

Heart failure continues to be a leading cause of morbidity and mortality worldwide. Symptoms and signs should be integrated with biomarkers and cardiac-imaging modalities for the diagnosis of heart failure where possible. Prevention of heart failure might be improved by better control of cardiovascular risk factors, including hypertension, possibly by lowering of systolic blood pressure targets in patients at increased risk of cardiovascular events and in those with diabetes, in whom

Search strategy and selection criteria

We searched PubMed from June 1, 2016, to Dec 31, 2016 with the terms ā€œheart failureā€ or ā€œcardiac dysfunctionā€ or ā€œleft ventricular dysfunctionā€, in combination with the terms ā€œguidelinesā€, ā€œstatementā€, ā€œepidemiologyā€, ā€œpathophysiologyā€, ā€œneurohormonalā€, ā€œgeneticsā€, ā€œgeneticā€, ā€œsymptomā€, ā€œsignā€, ā€œdiagnosisā€, ā€œlaboratoryā€, ā€œironā€, ā€œanaemiaā€, ā€œkidneyā€, ā€œrenalā€, ā€œcreatinineā€, ā€œnitrogenā€, ā€œhepaticā€, ā€œliverā€, ā€œtransaminasesā€, ā€œalbuminā€, ā€œsodiumā€, ā€œpotassiumā€, ā€œchlorideā€, ā€œechocardiographyā€,

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