Why we love heart failure: an introduction to the universal definition of heart failure

Abstract

“Stat rosa pristina nomine, nomina nuda tenemus” “The rose of old remains only through its name and we hold only bare names.” Umberto Eco. Il nome della rosa We both started to think about, and to research on, HF about 40 years ago, right with the publication of the first edition of Braunwald's textbook in 1980. That textbook was so clear. It was the first time for us that we found all essentials of pathophysiology, diagnosis and therapy of heart disease so clearly shown in one place.3 It was also the first time that we found a definition of HF usable in everyday clinical work and this was the time that we both fell in love with this syndrome. A name, a definition, may not be all, but it comes close. We define a syndrome. We have something to defeat. As more as we contemplate medicine, as more it seems that it is done by names and clear definitions. One of the most recent and devastating diseases we had, coronavirus disease 2019, was soon very clearly defined by a name, COVID-19, and while we still did not know anything of this disease, we could start searching in PubMed or Google for COVID-19 plus whatever is of interest and everything started coming out in increased clarity. HF was also not clear before we started having a definition. It was already clearly important but we did not have a clear enemy behind the name of HF. Dr Braunwald clearly defined HF and it was the first time we had something clear to fight against. Then, the methodology of randomized controlled trials was applied to HF and we had further definitions. The Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS) enrolled patients with a diagnosis of HF ‘… based on clinical criteria: a history of heart disease with symptoms of dyspnea or fatigue or both, together with signs of fluid retention and no evidence of primary pulmonary disease. The patients were symptomatic at rest (NYHA functional class IV). (…) Measurements of myocardial function were not required.’4 Better patients' characterization started in the Veterans Administration Cooperative Study comparing hydralazine–isosorbide dinitrate combination with prazosin and placebo.5 Eligibility for this trial ‘was based on evidence of cardiac dilatation at (…) chest x-ray film or (..) echocardiography or left ventricular (…) radionuclide ejection fraction <45% in association with reduced exercise tolerance, as assessed by a progressive maximal bicycle-ergometer exercise test’.5 Then, measurement of left ventricular ejection fraction (LVEF) became widely available through echocardiography and the Studies of Left Ventricular Dysfunction (SOLVD) introduced the criterion of a low LVEF, ‘of 0.35 or less’ as an integral component of the definition of HF.6 However, it was only in 1995 that the task force of the European Society of Cardiology (ESC) published guidelines for the diagnosis of HF which, as nicely stated by Braunwald, ‘went beyond symptoms’ and ‘also required objective evidence of cardiac dysfunction in the definition’.7 The figure in the Braunwald and Antman editorial outlines this: major discoveries and step forward in HF treatment went along with milestones in the definition of HF.2 Thus, nothing closer to truth than the quotation by Albert Einstein that Gregg Fonarow used in another enlightening recent editorial comment: ‘Many of the things you can count, don't count. Many of the things you can't count, really count.’8 There is no number in a definition, nothing that can be measured, but a definition can change our life and, hopefully, that of our patients, too.