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Key Clinical Questions

Heart Failure With Reduced Ejection Fraction (HFrEF)

  • image What is the definition and classification of HF?

  • image What is the mortality and morbidity of HF?

  • image What is the recommended testing for a patient with newly diagnosed HF?

  • image What are the standard therapies for HF?

  • image How can we remove congestion in HF?

HF With Preserved Ejection Fraction (HFpEF)

  • image How do you diagnose HF?

  • image What are the predisposing risk factors for HFpEF?

  • image What is the recommended evaluation for patients newly diagnosed with HF?

  • image How do you treat HF?


Heart failure (HF) is a condition that affects nearly 6 million people in the United States and 870,000 people are newly diagnosed each year. Its incidence increases with age, with rates approaching 10 per 1000 people after 65 years of age. Heart failure is a leading cause of hospital admissions in the United States and is responsible for over half a million emergency room visits, 1 million admissions and nearly 2 million office visits annually. Over the past decade, the rate of hospital admissions with a primary diagnosis of HF has remained elevated. After a hospital admission for HF, 25% of patients will be readmitted within a month, 50% within 6 months. Those at highest risk have an inpatient mortality as high as 20% to 25%.

The incidence and absolute number of HF deaths has continued to increase steadily (despite advances in HF therapy), in part due to aging of the population and improved survival after acute myocardial infarction (MI). Despite improvements in HF survival, mortality remains high; 50% of patients with HF will die within 5 years of the diagnosis. Approximately, 300,000 patients die of HF in the United States each year. The estimated direct and indirect cost of HF is $30.7 billion per year, and this total cost is expected to increase to 70 billion in the next 15 years.

The socioeconomic impact and significant burden that HF imposes on health care systems have led to the development of initiatives to reduce health care costs and improve patient outcomes. For example, the American Heart Association (AHA) Get With The Guidelines–Heart Failure Program is a collaborative quality improvement registry designed to improve adherence to evidence-based HF care of hospitalized patients, which has resulted in improved outcomes (eg, a reduction in 30-day readmission rates). The HF achievement measures of this program include:

  • Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) at discharge

  • Evidence-based use of specific β-blockers

  • Measurement of left ventricular (LV) function

  • Postdischarge appointment for HF patients

In addition, The Joint Commission on Accreditation of Health care Organizations has developed core measures for advanced certification in the management of HF (Table 129-1).

TABLE 129-1Performance Measures for Advanced Certification in HF

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