Global cardiology leaders are overhauling how heart failure is defined, warning that patients may still be at risk even when standard tests appear normal. Their new international consensus, published in the journal Circulation, updates a 2019 framework that had been adopted around the world.
The document, developed by experts from the American Heart Association, American College of Cardiology, World Heart Federation and European Society of Cardiology, argues that old definitions were too narrow. They say a more flexible and precise approach could improve diagnosis, treatment and even prevention.
Why the definition is changing
Heart failure affects more than 55 million people worldwide and is a leading cause of hospital admission and healthcare spending. Yet its definition and classification have long varied between countries, medical societies and clinical trials.
The new consensus stresses that heart failure is not a fixed label but a clinical syndrome that can worsen, stabilize or improve over time. It is driven by structural or functional problems that impair the heart’s ability to pump or fill with blood, and it can present very differently from one person to another.
Mary Norine Walsh, a cardiologist who co-chaired the writing group, said in a Circulation podcast that consistent terminology is crucial for patients. She argued that clear definitions help people understand their condition and make informed decisions about treatment and lifestyle.
Beyond ejection fraction alone
For decades, diagnosis and research have leaned heavily on a single measure called ejection fraction, or EF. This test estimates the percentage of blood the heart’s main pumping chamber pushes out with each beat and is typically assessed with ultrasound imaging.
The new paper warns that relying too strictly on EF can mislead both doctors and patients. EF can vary with age, sex and ethnicity, and it may appear normal while other signs show the heart is under strain. Some patients with normal EF still develop symptoms, hospitalizations and poor outcomes.
The authors call for a shift away from rigid EF cutoffs that have traditionally defined trial eligibility and treatment categories. They emphasize combining EF with imaging findings, blood biomarkers, clinical symptoms and, when appropriate, genetic testing to capture the full picture of heart function.
Recognizing heart failure’s many causes
A major addition in the consensus is a structured list of 18 categories of underlying causes, ranging from blocked coronary arteries and high blood pressure to valve disease and abnormal heart rhythms. The goal is to move beyond a simple split between ischemic and non-ischemic disease.
The authors highlight that causes differ widely across regions. In many high-income countries, coronary artery disease and hypertension dominate, while in low- and middle-income nations, infections, rheumatic valve disease, pregnancy-related problems and untreated high blood pressure may be more prominent.
Other contributors in the list include inflammatory and autoimmune conditions, inherited cardiomyopathies, metabolic and nutritional disorders, alcohol and drug toxicity, cancer therapies, and extreme physical or emotional stress. Each category may call for different investigation and tailored treatment.
Implications for care and prevention
Recent research suggests that nearly 85 percent of people later diagnosed with heart failure had at least one modifiable risk factor documented in the five years before diagnosis. Those risks include uncontrolled blood pressure, diabetes, obesity, smoking and coronary artery disease.
By labeling and tracking causes more precisely, clinicians may be able to intervene earlier with targeted therapies, lifestyle support and closer monitoring. The authors also hope the framework will spur better-designed clinical trials that reflect the true diversity of patients.
The consensus is not itself a treatment guideline, but it is expected to guide future recommendations from major societies. Walsh noted that updated clinical guidance aligned with the new universal definition is already in development and will likely influence practice over the coming years.
The authors and fact-checkers acknowledge that evidence will continue to evolve and invite feedback from clinicians and researchers. They argue that refining definitions is an essential step toward reducing the global burden of heart failure and improving long-term outcomes for patients.
