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is generally believed that, of those with HF, about 50% have HFrEF and 50% have HFpEF/HFmrEF, mainly based on studies in hospitalized patients.32,35,37,38 The ESC Long-Term Registry, in the outpatient setting, reports that 60% have HFrEF, 24% have HFmrEF, and 16% have HFpEF.39 Somewhat more than 50% of HF patients are female.21,40,41

3.3.2 Aetiology of heart failure The most common causes (as well as some key investigations) of HF are shown in Table 5. The aetiology of HF varies according to geography. In Western-type and developed countries, coronary artery disease (CAD) and hypertension are predominant factors.27 With regard to ischaemic aetiology, HFmrEF resembles HFrEF, with a higher frequency of underlying CAD compared to those with HFpEF.38,42,43

3.3.3 Natural history and prognosis The prognosis of patients with HF has improved considerably since the publication of the first treatment trials a few decades ago. However, it remains poor, and quality of life (QOL) is also markedly reduced. The improvement in prognosis has been confined to those with HFrEF. Mortality rates are higher in observational studies than in clinical trials.44 In the Olmsted County cohort, 1-year and 5-year mortality rates after diagnosis, for all types of HF patients, were 20% and 53%, respectively, between 2000 and 2010.45 A study combining the Framingham Heart Study (FHS) and Cardiovascular Health Study (CHS) cohorts reported a 67% mortality rate within 5 years following diagnosis.46 Despite receiving less evidence-based treatment, women have a better survival than men.47 Overall prognosis is better in HFmrEF compared to HFrEF.39 Of note, transition in ejection fraction over time is common, and patients who progress from HFmrEF to HFrEF have a worse prognosis than those who remain stable or transition to a higher ejection fraction category.4852

HFpEF is generally considered to confer a better survival than HFrEF, but most observational studies show that this difference is negligible.45,46 In contrast, the large MAGGIC meta-analysis concluded that the adjusted mortality risk for patients with HFpEF was considerably lower than in patients with HFrEF.53 Studies from several countries have shown that between 1980 and 2000 survival in HF patients has improved markedly.41,5457 However, this positive trend may have levelled off since then.45 After the initial diagnosis, HF patients are hospitalized once every year on average.54 From 2000 to 2010, the mean rate of hospitalization in the Olmsted County cohort was 1.3 per person-year. Interestingly, the majority (63%) of hospitalizations were related to non-CV causes.45 Studies from several European countries and the United States (US) have shown that HF hospitalization rates peaked in the 1990s, and then declined.54,55*,5860 However, in a recent study of incident HF conducted between 1998 and 2017 in the United Kingdom (UK), age-adjusted rates of first hospitalizations increased by 28% for both all-cause and HF admissions, and by 42% for non-CV admissions.61 These increases were higher in women, perhaps related to higher comorbidity rates. The risk of HF hospitalization is 1.5 times higher in patients with diabetes compared to controls. AF, a higher body mass index (BMI), and higher glycated haemoglobin (HbA1c), as well as a low estimated glomerular filtration rate (eGFR) are strong predictors of HF hospitalizations.29 Due to population growth, ageing, and the increasing prevalence of comorbidities, the absolute number of hospital admissions for HF is expected to increase considerably in the future, perhaps by as much as 50% in the next 25 years.24,62

4 Chronic heart failure

4.1 Key steps in the diagnosis of chronic

heart failure The diagnosis of CHF requires the presence of symptoms and/or signs of HF and objective evidence of cardiac dysfunction (Figure 1). Typical symptoms include breathlessness, fatigue, and ankle swelling (Table 6). Symptoms and signs lack sufficient accuracy to be used alone to make the diagnosis of HF.6366 The diagnosis of CHF is made more likely in patients with a history of MI, arterial hypertension, CAD, diabetes mellitus, alcohol misuse, chronic kidney disease (CKD), cardiotoxic chemotherapy, and in those with a family history of CMP or sudden death. The following diagnostic tests are recommended for the assessment of patients with suspected chronic HF:

(1) Electrocardiogram (ECG). A normal ECG makes the diagnosis of HF unlikely.63 The ECG may reveal abnormalities such as AF, Q waves, LV hypertrophy (LVH), and a widened QRS complex (Table 7) that increase the likelihood of a diagnosis of HF and also may guide therapy.

Table 4 New York Heart Association functional classification based on severity of symptoms and physical activity

Class I No limitation of physical activity. Ordinary physical activity

does not cause undue breathlessness, fatigue, or palpitations.

Class II Slight limitation of physical activity. Comfortable at rest,

but ordinary physical activity results in undue breathlessness, fatigue, or palpitations.

Class III Marked limitation of physical activity. Comfortable at rest,

but less than ordinary activity results undue breathlessness, fatigue, or palpitations.

Class IV Unable to carry on any physical activity without discom-

fort. Symptoms at rest can be present. If any physical activity is undertaken, discomfort is increased. ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026