Spurred by great enthusiasm for the latest treatments for heart failure, some groups are putting greater emphasis on clearly defining what exactly heart failure is, and how to communicate it to patients without demoralizing them.
There are now five classes of life-saving heart failure drugs, as angiotensin receptor-neprilysin inhibitors and SGLT2 inhibitors were added to heart failure treatment algorithms in new guidance from the American College of Cardiology (ACC).
This is an "exciting time," said Anuradha Lala, MD, of Mount Sinai Health System in New York City. "Now our efforts need to be focused on implementation, making sure that patients who will benefit from these medications are actually on these medications."
A More Comprehensive Definition of Heart Failure
As such, the new universal definition of heart failure -- drafted by the Heart Failure Society of America, European Society of Cardiology, and Japanese Heart Failure Society -- helps clarify who exactly would be eligible for which therapies and future trials according to clear cutoffs for reduced, preserved, mildly reduced, and improved ejection fraction.
There are lots of definitions of heart failure floating around, but the universal definition is more complete and accurate than any prior ones, according to Maya Guglin, MD, PhD, of Indiana University School of Medicine in Indianapolis and chair of the ACC council of heart failure and transplant as well as a reviewer for the consensus statement.
"We all pretty much agree on what heart failure is," Guglin told MedPage Today.
The new document adds the knowledge about heart failure that has been gained since the ACC and American Heart Association last defined heart failure as "a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood" in 2013 guidelines.
"Our understanding of heart failure, its pathophysiology, its prognosis ... it's evolving. It's not surprising that 7, 8 years later there was a need for another more comprehensive or more modern definition of heart failure that reflects our current understanding of the concept," Guglin said.
In particular, she cited better understanding of the greater unifying role of congestion or ventricular filling, with ejection fraction being of less importance than previously thought.
Accordingly, the universal definition of 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."
'Function' Not 'Failure'
Notably, the new definition also introduces clearer, more precise language. For example, the authors favor describing heart failure that is "persistent" or "in remission" rather than "stable." Additionally, "pre-heart failure" now describes patients who have structural abnormalities but no symptoms.
The importance of word choice was highlighted by an editor's note in the Journal of Cardiac Failure by Lala and editor-in-chief Robert Mentz, MD, of Duke University Medical Center in Durham, North Carolina, published in the same issue as the new universal definition.
"Few words in the English language universally invoke the negative emotions of fear and disappointment as does the word 'failure,'" the duo wrote.
"Our introductions in the clinical space may be met with fear and disappointment, even as we provide reassurance as to advances in therapy, and attempt to instill hope for continued life with improved quality -- despite the diagnosis. Some patients prefer to not confront the notion of failure at all, and delay or avoid care all together," Lala and Mentz said.
They proposed greater adoption of the term "heart function" when communicating with patients, as is the case in Canada, for instance, where patients visit "heart function clinics."
"Our hope is that being clear on definitions and intentional with our words will allow for more implementation of guideline-directed medical therapy and best practices to improve outcomes for our patients," Lala said in an interview.
"If we move our vernacular to speaking more about 'function' and focusing on its improvement, then it could potentially allow for a more fruitful interaction and engagement between patients and their clinicians and caregivers," she said. "Focusing on 'function' allows for inclusion of speaking about prevention and lifestyle, whereas 'failure' implies in a way that we've reached some end of the spectrum that may not necessarily be addressable."
Guglin agreed with the use of "heart function" and the change in language depending on whether one is speaking to other health professionals or a layperson.
Ultimately, she emphasized, the goal is always for information to be conveyed as accurately as possible. "When it comes to patients, yes, we don't want to scare them too much, but on the other hand, you have to convey the seriousness of the issue. Otherwise, they will not take recommendations as closely to heart," she warned.
Lala acknowledged concerns that pivoting from "failure" to "function" may appear to minimize the severity of the disease.
For patients who truly have the clinical syndrome of heart failure, "I do reiterate that they have heart failure, the gravity of the disease, and that the goal is to institute guideline-directed therapies to facilitate a transition to heart failure in remission," she explained. "But for those patients who are not symptomatic, or were symptomatic and now feel better or whose function has improved from a variety of standpoints, incorporating the word 'function' in our visits more and more has anecdotally been empowering."
Moving forward, it would be important to study how patients' behaviors and perceptions of their disease may change depending on how clinicians talk to them, Lala said.
"We know so many heart failure patients are referred to heart failure teams too late in the course of their disease," she noted. "If [the phrase] didn't have negative connotations, would they come earlier? Would they be potentially more engaged or receptive to see us? How would it affect their quality of life?"
Disclosures
Lala, Guglin, and Mentz noted no disclosures.
Primary Source
Journal of Cardiac Failure
Source Reference: Lala A, Mentz RJ "Contemplation from our hearts: a call to shift from failure to function" J Card Fail 2021; DOI: 10.1016/j.cardfail.2021.03.002.
