New heart failure definition aims to catch disease before symptoms start

Clinical Takeaway: Do not rely on a single EF cutoff, natriuretic peptide result, or “stable HF” label; assess symptoms, signs, biomarkers, imaging, cause, trajectory, and risk factors together, and continue guideline-directed therapy and follow-up in patients whose EF improves.

The AHA/ACC/ESC/WHF Second Universal Definition of Heart Failure updates the 2021 framework to better reflect how HF is diagnosed, prevented, and tracked in modern practice. The document is not a treatment guideline, but it highlights where diagnosis and staging should prompt earlier, more individualized risk reduction.

A key shift is the move away from rigid left ventricular ejection fraction thresholds. HF is now grouped into clinically actionable categories: HF with reduced EF, HF with preserved EF, and HF with improved EF. The authors emphasize that EF can vary by measurement method and patient factors and should not be the only determinant of diagnosis or management.

The document also reinforces stage A and pre-HF (stage B) as major opportunities for prevention. For patients with risk factors such as diabetes, obesity, chronic kidney disease, hypertension, or asymptomatic LV dysfunction, the consensus highlights therapies shown to reduce incident HF risk, including antihypertensives, diabetes and obesity treatments, SGLT2 inhibitors, GLP-1 receptor agonists, finerenone in chronic kidney disease with diabetes, and selected renin-angiotensin-aldosterone system inhibitors and beta-blockers in asymptomatic LV dysfunction.

What’s changed

EF categories are simplified: reduced EF, preserved EF, and improved EF replace reliance on fixed numerical cutoffs.

The definition gives more weight to HF trajectories: improvement, remission, and recovery are distinct states, and improved EF does not mean cure.

“Stable HF” is discouraged as misleading because patients remain at risk for worsening symptoms, hospitalization, sudden cardiac death, and relapse.

A universal classification of HF causes is introduced, spanning ischemic, hypertensive, valvular, arrhythmia-related, infiltrative, infective, inflammatory, toxic, heritable, metabolic/nutritional, pregnancy-related, stress-induced, pulmonary/right-sided, congenital, high-output, other, and idiopathic causes.

Geographic variation and social determinants of health are explicitly incorporated, recognizing that HF causes and access to diagnosis and treatment differ widely across regions and populations.

Worsening HF and decompensated HF are more clearly distinguished: worsening HF reflects deterioration in a patient with established HF, while decompensated HF requires treatment intensification or rescue therapy.

The authors frame the update as “a living framework” that should evolve with future discoveries and innovations, “always with the goal of improving patient care and outcomes.”

Source: Walsh MN, et al. (2026 June 29) Circulation. AHA/ACC/ESC/WHF Expert Consensus Document: Second Universal Definition of Heart Failure (2026)