Redefining Heart Failure With a Reduced Ejection Fraction

The current management of patients with chronic heart failure depends on the noninvasive measurement of left ventricular ejection fraction (LVEF). In patients with an LVEF of 40% or lower, large-scale randomized clinical trials have demonstrated the benefits of inhibitors of the renin-angiotensin system, sympathetic nervous system, aldosterone, and neprilysin in reducing the risk of cardiovascular death and hospitalization for heart failure. Because these trials only enrolled patients with an LVEF of 40% or lower, a value of 40% has been used to define patients with heart failure and a reduced ejection fraction (HFrEF) for the past 30 years. Current guidelines strongly recommend the use of combination treatment with neurohormonal antagonists for patients with HFrEF.1 By contrast, there are no evidence-based recommendations concerning the treatment of patients with LVEF greater than 40%, who have been conventionally referred to as having heart failure with a preserved ejection fraction (HFpEF). This lack of guidance is a concern because such patients now represent a majority of those with heart failure in the general community, particularly among women.

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