Experts Release Second Universal Definition of Heart Failure to Improve Diagnosis and Patient Care
USA: Heart failure (HF) affects millions of people worldwide and continues to be a leading cause of illness and death. To improve consistency in diagnosis, research, and patient care, leading international cardiovascular organizations have released the Second Universal Definition of Heart Failure (2026).
The updated expert consensus introduces refined definitions of heart failure stages, adopts a more clinically relevant approach to classifying heart failure based on ejection fraction, proposes a universal classification of heart failure causes, and recognizes that heart failure can improve, enter remission, or even recover over time. The document also highlights the influence of social determinants of health and geographic differences on heart failure risk and outcomes.
Published in Circulation, the consensus statement was developed by Mary Norine Walsh, MD (United States), and an international panel of experts representing the American Heart Association (AHA), American College of Cardiology (ACC), European Society of Cardiology (ESC), and World Heart Federation (WHF).
The updated definition builds on the first Universal Definition of Heart Failure released in 2021. Since then, advances in heart failure prevention, diagnosis, treatment, and a growing understanding of patient experiences have prompted experts to revise the framework. The goal is to establish a common language that can be used by clinicians, researchers, health systems, and policymakers worldwide while promoting earlier identification of individuals at risk.
One of the major updates is the continued emphasis on the four stages of heart failure progression. Stage A includes individuals who have risk factors such as hypertension, diabetes, obesity, coronary artery disease, congenital heart disease, cardiotoxic drug exposure, or a family history of cardiomyopathy but show no structural heart disease or symptoms. Stage B (pre-HF) refers to people without symptoms but with evidence of structural heart abnormalities, impaired cardiac function, or elevated cardiac biomarkers. Stage C includes patients with current or previous symptoms caused by structural or functional cardiac abnormalities, while Stage D represents advanced heart failure requiring specialized therapies such as mechanical circulatory support, heart transplantation, or palliative care.
Another significant change is the shift away from rigid left ventricular ejection fraction (LVEF) cutoffs. Instead, the consensus recommends broader, clinically meaningful categories of heart failure with reduced, preserved, and improved ejection fraction, acknowledging that cardiac function exists along a continuum and that patients may transition between categories during treatment.
The document also introduces a standardized global classification of heart failure causes. Rather than relying on varying regional systems, it groups heart failure into major pathogenic categories, including ischemic, hypertensive, valvular, arrhythmia-related, infiltrative, infective, inflammatory, toxic, heritable, congenital, metabolic, pregnancy-related, stress-induced, pulmonary, high-output, idiopathic, and other cardiomyopathies. According to the authors, this framework may improve diagnostic accuracy, facilitate research, and support more targeted treatment strategies.
Another important addition is the recognition that heart failure follows dynamic clinical trajectories. The consensus distinguishes improvement, remission, and recovery as separate clinical states, emphasizing that even patients whose symptoms improve require continued follow-up because the disease may recur.
Key highlights of the Second Universal Definition of Heart Failure
- Refines the definitions of heart failure stages from Stage A (at risk) through Stage D (advanced HF), with greater emphasis on identifying pre-heart failure (Stage B).
- Continues to recognize pre-HF as a stage where structural abnormalities, impaired cardiac function, or elevated biomarkers are present despite the absence of symptoms.
- Replaces rigid left ventricular ejection fraction (LVEF) cutoffs with broader categories of reduced, preserved, and improved ejection fraction to better reflect clinical practice.
- Introduces a universal classification of heart failure causes, including ischemic, hypertensive, valvular, inflammatory, toxic, heritable, metabolic, congenital, pregnancy-related, and other cardiomyopathies.
- Recognizes that heart failure is dynamic, with patients potentially experiencing improvement, remission, or recovery, rather than following a single progressive course.
- Highlights the impact of social determinants of health, healthcare access, and geographic variation on heart failure risk, diagnosis, treatment, and outcomes.
- Encourages earlier detection, individualized risk reduction, and standardized terminology to improve research, clinical care, and global surveillance.
The experts also stress that heart failure care extends beyond cardiac function alone. The updated document emphasizes the importance of recognizing conditions that mimic heart failure, distinguishing them from true heart failure syndromes, and considering the patient's overall clinical context. It further underscores that differences in healthcare access, socioeconomic conditions, and regional disease patterns contribute substantially to variations in heart failure outcomes across the world.
Overall, the authors describe the Second Universal Definition of Heart Failure as an evolving framework designed to reflect advances in cardiovascular science and clinical practice. By standardizing terminology, refining disease staging, recognizing diverse disease trajectories, and promoting a universal classification of underlying causes, the consensus aims to improve prevention, facilitate earlier diagnosis, support personalized management, and ultimately enhance cardiovascular outcomes worldwide.
Reference: https://doi.org/10.1161/CIR.0000000000001455
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