The struggle towards a Universal Definition of Heart Failure—how to proceed?

We propose a Universal Definition of Heart Failure based on the pathophysiological concept of “cardiac dysfunction with congestion”; congestion being defined as high atrial and venous pressures. In clinical practice, increased plasma concentrations of natriuretic peptides and atrial dilation are the hallmarks of congestion. Currently, the diagnosis of heart failure is based on symptoms and signs that are neither sensitive nor specific and often ignored until severe enough to precipitate hospitalisation. Cardiac dysfunction and congestion commonly exist and progress for years before the onset of symptoms. The consequences of delayed diagnosis may be severe. Objective and verifiable diagnostic criteria for heart failure are desirable for many reasons, but particularly to improve patient management and outcomes and scientific communication. Enabling early diagnosis encourages timely intervention to slow, halt or reverse disease progression. Myocardial secretion of natriuretic peptides is a key physiological defence against congestion; only when this defence is overwhelmed will congestion become clinically overt. Accordingly, increased plasma concentrations of natriuretic peptides due to cardiac dysfunction, rather than symptoms, should be prerequisite for the diagnosis of heart failure. Atrial dilation confirms a cardiac cause for the increase in natriuretic peptides. This definition of heart failure would bring it into line with those for other common medical conditions such as myocardial infarction, diabetes and hypertension, that are based on a combination of pathophysiological concepts supported by objective measurements rather than delaying diagnosis until the onset of symptoms. This new definition will have profound effects on the prevalence and management of heart failure.