Table 1
Stages in the Development and Progression of HF.
| STAGE | DEFINITION |
|---|---|
| At risk for HF (stage A) | Individuals at risk for HF but without current or prior symptoms or signs of HF and without structural cardiac changes or elevated biomarkers of heart disease At risk: individuals with hypertension, atherosclerotic cardiovascular disease, congenital heart disease, diabetes, obesity, exposure to cardiotoxins, a family history of cardiomyopathy, or genetic carriers at risk for cardiomyopathy Not all will develop HF, but risk factor intervention may be warranted |
| Pre-HF (stage B) | Individuals without current or prior symptoms or signs of HF with evidence of one of the following:
|
| HF (stage C) | Individuals with current or prior symptoms or signs of HF or both caused by a structural or functional cardiac abnormality or both |
| Advanced HF (stage D) | Severe symptoms or signs of HF or both at rest or with minimal exertion, recurrent hospitalizations despite GDMT, refractory or intolerant to GDMT, requiring advanced therapies such as inotropic support and consideration for cardiac transplantation, mechanical circulatory support, or palliative care |
[i] GDMT indicates guideline directed medical therapy; and HF, heart failure.
Table 2
Selected Recently Proposed Classifications of HF by Cause.
| CLASSIFICATION (REFERENCE) | PATHOGENIC CLASSES |
|---|---|
| European Society of Cardiology HF guidelines 2021 (9) | Coronary artery disease; hypertension; valve disease; arrhythmias; cardiomyopathies; congenital heart disease, infective, drug induced, infiltrative; storage disorders; endomyocardial disease; pericardial disease, metabolic; neuromuscular disease |
| American Heart Association/American College of Cardiology/Heart Failure Society of America HF guidelines 2022 (10) | Ischemic heart disease and myocardial infarction; hypertension; valvular heart disease; familial or genetic cardiomyopathies; amyloidosis; cardiotoxicity with cancer or other treatments or substance abuse such as alcohol, cocaine, or methamphetamine; tachycardia, right ventricular pacing, or stress-induced cardiomyopathies; peripartum cardiomyopathy; myocarditis; autoimmune causes, sarcoidosis; iron overload, including hemochromatosis; thyroid disease and other endocrine metabolic; nutritional |
| Global Burden of Disease (42) | Ischemic cardiomyopathy; pressure overload of the left side of the heart; pulmonary heart disease; valvular and congenital cardiomyopathy; primary myocardial disease; toxic cardiomyopathy; infectious disease; stress, tachycardias, and high-output mediated cardiomyopathy; volume-overload syndromes; other causes |
[i] HF indicates heart failure.
Table 3
Proposed Universal Classification of HF by Cause.
| PATHOGENIC GROUP | SPECIFIC EXAMPLES |
|---|---|
| Ischemic cardiomyopathy | Ischemic heart disease, myocardial infarction, coronary artery disease |
| Hypertensive cardiomyopathy | Hypertensive heart disease |
| Valvular cardiomyopathy | Structural valve disease: calcific aortic valve disease, degenerative mitral valve disease, other nonrheumatic and congenital valvular diseases, rheumatic heart disease |
| Arrhythmia-related cardiomyopathy | Atrial fibrillation (uncontrolled), tachycardia, dyssynchrony, or premature ventricular contraction–induced cardiomyopathy, right ventricular pacing–induced cardiomyopathy, desmoplakin |
| Infiltrative cardiomyopathy | Cardiac amyloidosis, hemochromatosis, Fabry disease, glycogen storage disease, neoplastic/cancer-related infiltration |
| Infective cardiomyopathy | Viral myocarditis, Chagas disease, HIV, Lyme disease |
| Inflammatory cardiomyopathy | Autoimmune disease, sarcoidosis, hypersensitivity, desmoplakin |
| Toxic cardiomyopathy | Medication-induced cardiotoxicity, substance use disorders, for example, alcohol, cocaine, amphetamine |
| Heritable cardiomyopathy | Hypertrophic cardiomyopathy, dilated cardiomyopathy, restrictive cardiomyopathy, arrhythmogenic cardiomyopathy, nondilated left ventricular cardiomyopathy |
| Pericardial disease | Constrictive and restrictive pericarditis |
| Metabolic disease and nutritional deficiency–associated cardiomyopathy | Obesity; diabetes; endocrine disorders, for example, thyroid disease; nutritional disease, for example, thiamine, vitamin B1, and selenium deficiencies; inborn errors of metabolism |
| Pregnancy-related cardiomyopathy | Peripartum cardiomyopathy |
| Stress-induced cardiomyopathy | Takotsubo cardiomyopathy |
| Pulmonary/right-sided heart disease | Chronic obstructive pulmonary disease, interstitial lung disease, coal workers’ pneumoconiosis, silicosis, asbestosis, other pneumoconiosis, pulmonary arterial hypertension |
| Congenital cardiomyopathy | Systemic right ventricular failure, Fontan circulation, repaired tetralogy of Fallot |
| High-output mediated cardiomyopathy | Hemoglobinopathies, hemolytic anemias, atrioventricular malformations, endocrine causes (eg, pheochromocytoma) |
| Other causes | Other cardiovascular and systemic disorders, for example, neuromuscular disease, endomyocardial fibrosis, Loeffler endocarditis |
| Idiopathic | Idiopathic cardiomyopathy |
[i] HF indicates heart failure.
Figure
Trajectories of HF.
An individual’s heart failure (HF) journey starts left to right, and quality of life or exercise capacity and prognosis become poor as HF stage advances. Every stage carries certain risk of sudden death.
| WRITING GROUP MEMBER | EMPLOYMENT | RESEARCH GRANT | OTHER RESEARCH SUPPORT | SPEAKERS’ BUREAU/HONORARIA | EXPERT WITNESS | OWNERSHIP INTEREST | CONSULTANT/ADVISORY BOARD | OTHER |
|---|---|---|---|---|---|---|---|---|
| Mary N. Walsh | Ascension St. Vincent Heart Center (United States) | None | None | None | None | None | None | None |
| Lars Køber | Rigshospitalet, Copenhagen University Hospital (Denmark) | None | None | AstraZeneca*; Bayer*; Boeringer Ingelheim*; Novartis*; Novo Nordisk* | None | None | None | None |
| Karen Hahnle-Sliwa | Cape Heart Institute (South Africa) | None | None | None | None | None | None | None |
| Marianna Adamo | Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia (Italy) | None | None | None | None | None | None | None |
| Anubha Agarwal | Washington University in St. Louis School of Medicine (United States) | NIH (R00HL157687, R33HL139852)†; Washington University in St. Louis† | None | None | None | HFrEF polypill patent pending† | None | None |
| Amitava Banerjee | University College London Institute of Health Informatics (United Kingdom) | None | None | None | None | None | None | None |
| Biykem Bozkurt | Baylor College of Medicine (United States) | None | None | None | None | None | ABIOMED/Johnson and Johnson*; AstraZeneca*; Bayer*; Bristol Myers Squibb*; Boehringer Ingelheim*; Cardurion*; Cytokinetics*; Eli Lilly*; Medtronic*; Merck*; Idorsia*; Novo Nordisk*; Regeneron*; Renovacor*; Roche*; Salubris*; Sanofi-Aventis*; scPharmaceuticals*; Vasa Therapeutics (DSMC) Vifor*; Respicardia/Zoll* | None |
| Maja Cikes | Sveuciliste u Zagrebu Medicinski fakultet Department for Cardiovascular Diseases (Croatia) | Novartis (Investigator-Initiated Research Grant to institution)*; Novo Nordisk (Clinical Study Contract with institution)*; CorVia (Clinical Study Contract with institution)* | None | Abbott*; Bayer*; Novo Nordisk†; Pfizer*; Medscape† | None | None | Bayer*; Boehringer-Ingelheim*; Novo Nordisk*; Biogen*; Astra Zeneca (Steering committee member)*; Novo Nordisk (Steering committee member)†; Corteria (Steering committee member)* | None |
| Albertino Damasceno | Universidade Eduardo Mondlane (Mozambique) | None | None | None | None | None | None | None |
| Akshay Desai | Brigham and Women’s Hospital (United States) | Alnylam (institutional grant to BWH)†; AstraZeneca (institutional grant to BWH)†; Bayer (institutional grant to BWH)†; Avalyn Pharma (institutional grant to BWH)†; Pfizer (institutional grant to BWH)†; Intellia Therapeutics (institutional grant to BWH)†; Pharmacosmos (institutional grant to BWH)† | None | None | None | None | Abbott*; Alnylam†; AstraZeneca†; Avidity Bioscience†; Axon Therapies*; Bayer†; Biofourmis*; CVS Caremark†; Corsera Health*; Corteria Therapeutics*; Edwards Lifesciences†; Endrotronix†; iRhythm Technologies*; Medpace†; New Amsterdam†; Novartis*; Regeneron*; River2Renal†; Roche†; scPharma*; Teva†; Vectorious Medical Technologies†; Verve Therapeutics†; Volta Medical†; Whiteswell* | None |
| G. Michael Felker | Duke University Duke Clinical Research Institute (United States) | Cytokinetics (research grant to Duke)†; BMS (research grant to Duke)†; Bayer (research grant to Duke)† | None | None | None | None | Merck*; Boehringer Ingelheim†; Whiteswell*; Novartis*; River2Renal* | None |
| Gail Hogan | Retired (United States) | None | None | None | None | None | None | None |
| Koichiro Kinugawa | University of Toyama, Second Department of Internal Medicine (Japan) | None | None | None | None | None | None | None |
| Michelle Kittleson | Cedars Sinai Smidt Heart Institute (United States) | None | None | None | None | None | None | None |
| Carolyn Lam | Duke–National University of Singapore Graduate Medical School (Singapore) | Roche (principal investigator, Cardiovascular Clinical Trials in Asia: Asian Diabetes Outcomes Prevention Trial [ADOPT])†; Novo Nordisk (principal investigator, Clinical, imaging and biomarker exploration in HFpEF Patients from ATTRaCT cohort[s])†; National Medical Research Council of Singapore (principal investigator, Heart Failure Screening in Primary Care Using Digital Tools)† | None | None | None | Us2.ai† | Alnylam Pharma*; AnaCardio AB*; Applied Therapeutics*; AstraZeneca*; Boehringer Ingelheim*; Bristol Myers Squibb*; Corteria*; CPC Clinical Research*; Cytokinetics*; Impulse Dynamics*; Intellia Therapeutics*; Klyv Therapeutics*; Medscape*; Merck*; Pfizer*; Radcliffe*; Ribocure*; Roche*; Bayer†; Boston Scientific†; Eli Lilly†; Janssen R&D†; Novartis†; Novo Nordisk†; Us2.ai† | None |
| Theresa McDonagh | King’s College Hospital (United Kindgom) | None | None | Boehringer Ingelheim* | None | None | None | None |
| Marco Metra | Cardiology. IRCCS San Raffaele Scientific Institute and Vita-salute University Milan (Italy) | None | None | Boehringer Ingelheim*; Zoll Therapeutics*; Tenax Therapeutics* | None | None | Bayer*; Eli Lilly*; NovoNordisk*; Astra-Zeneca (Steering Committee member)* | None |
| Wilfried Mullens | Ziekenhuis Oost-Limburg (Belgium) | None | None | None | None | None | None | None |
| Antonio Ribeiro | Department of Internal Medicine, Faculdade de Medicina, and Telehealth Center and Cardiology Service, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte (Brazil) | None | None | None | None | None | None | None |
| Yolanda Vaughn | Tennessee Board of Regents (United States) | None | None | None | None | None | None | None |
| Amanda Vest | Cleveland Clinic (United States) | NIH (R01 and RCs2 grants)† | None | None | None | None | None | None |
[i] This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives EUR 10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns EUR 10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.
| REVIEWER | EMPLOYMENT | RESEARCH GRANT | OTHER RESEARCH SUPPORT | SPEAKERS’ BUREAU/HONORARIA | EXPERT WITNESS | OWNERSHIP INTEREST | CONSULTANT ADVISORY BOARD | OTHER |
|---|---|---|---|---|---|---|---|---|
| Johann Bauersachs | Hannover Medical School (Germany) | CVRx*; Roche Diagnostics*; Norgine (investigator iron deficiency in heart failure)†; Zoll* | None | Boehringer Ingelheim†; Bayer†; BMS†; AstraZeneca†; Cardior*; CVRx*; Abbott*; Edwards*; Zoll*; Pfizer*; Novartis* | None | None | None | None |
| Jan Biegus | University Clinical Hospital in Wroclaw, Institute of Heart Diseases, Wroclaw Medical University (Poland) | None | None | None | None | None | None | None |
| Barry A. Borlaug | Division of Cardiology, Mayo Clinic | None | None | None | None | None | None | None |
| Khadijah Breathett | Indiana University Division of Cardiology | NHLBI (advanced heart failure)† | None | None | None | None | Circulation: Population Health and Outcomes associate editor† | None |
| Erwan Donal | CHU de Rennes (France) | General Electric Healthcare* | None | Abbott (speaker fees)*; Pfizer (speaker fees)*; Alnylam (speaker fees)* | None | None | None | None |
| Michael M. Givertz | Brigham and Women’s Hospital | None | None | None | None | None | None | None |
| Eva Goncalvesova | National Institute of Cardiovascular Diseases (Slovakia) | None | None | Novartis*; Bayer*; Boehringer Ingelheim*; AstraZeneca*; Pfizer*; AOP*; Novo Nordisk*; Amgen* | None | None | Servier*; Boehringer Ingelheim*; Bayer* | None |
| Takeshi Kitai | National Cerebral and Cardiovascular Center (Japan) | None | None | None | None | None | None | None |
| Sarah M. Kraus | University of Cape Town (South Africa) | None | None | Sanofi African Rare Disease Summit (June 2025)* | None | None | Heart Failure Society of South Africa (HeFSSA)–Executive Committee member (uncompensated)* | None |
| Xinli Li | The First Affiliated Hospital With Nanjing Medical University (China) | None | None | None | None | None | None | None |
| Seema Mital | The Hospital for Sick Children (Canada) | None | None | None | None | None | Bristol Myers Squibb*; Tenaya Therapeutics*; Rocket Pharmaceuticals* | None |
| Pablo Perel | World Heart Federation | None | None | None | None | None | None | None |
| Nancy K. Sweitzer | Washington University School of Medicine in St. Louis | None | None | None | None | None | None | None |
| Jasper Tromp | National University of Singapore and National University Health System (Singapore) | AstraZeneca (research support for health economic analysis)† | None | None | None | Us2.ai* | Us2.ai*; Roche Diagnostics* | None |
| Eleanor Wicks | Oxford University (England) | None | None | None | None | None | None | None |
[i] This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all reviewers are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives EUR 10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns EUR 10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition.
*Modest.
†Significant.