Fast Five Quiz: Heart Failure With Reduced Ejection Fraction (HFrEF)

Yasmine S. Ali, MD


June 10, 2021

The ESC recognizes three types of HF: HFpEF, HFrEF, and HFmrEF. These categories are based on the measurement of left ventricular ejection fraction (LVEF). Patients with HF with normal LVEF (typically ≥ 50%) have HFpEF. Those with LVEF < 40% have HFrEF. And there is now a third "gray" category, HFmrEF, to represent the mid-range LVEF measurements (40%-49%).

The Framingham criteria for HF diagnosis consists of the concurrent presence of either two major criteria or one major and two minor criteria. Major criteria comprise the following:

  • Paroxysmal nocturnal dyspnea

  • Weight loss of 4.5 kg in 5 days in response to treatment

  • Neck vein distention

  • Rales

  • Acute pulmonary edema

  • Hepatojugular reflux

  • S3 gallop

  • Central venous pressure > 16 cm H20

  • Circulation time ≥ 25 sec

  • Radiographic cardiomegaly

  • Pulmonary edema, visceral congestion, or cardiomegaly at autopsy

Minor criteria (accepted only if not attributable to another medical condition) are as follows:

  • Nocturnal cough

  • Dyspnea on ordinary exertion

  • A decrease in vital capacity by one third the maximal value recorded

  • Pleural effusion

  • Tachycardia (heart rate ≥ 120 beats/min)

  • Hepatomegaly

  • Bilateral ankle edema

The NYHA uses classes of I to IV to categorize HF on the basis of physical activity ability, where class I indicates no limitation of physical activity and class IV indicates that symptoms occur even at rest and that there is discomfort with any physical activity.

The ACC/AHA also uses four categories, but these stages are based on structural abnormalities, from no structural disease (but the presence of risk factors) in stage A to the most severe patients requiring specialized interventions in stage D.

In addition, the HFSA/HFA/JHFS consensus statement offers revisions to HF staging in light of the evolving role of biomarkers.

Learn more about diagnostic, classification, and staging criteria in HF.


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