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  1. Rachel RosqvistSenior Lecturer1,
  2. Kyle EggletonSenior Lecturer1,
  3. bruce arrollProfessor1,
  4. ralph stewartClinical Adjunct Professor2
  1. 1Department of General Practice and Primary Health Care, School of Population Health, University of Auckland, New Zealand.
  2. 2Department of Medicine, Faculty of Medicine, University of Auckland, New Zealand
  1. Correspondence: B. Alor Bruce Arroll{at}auckland.ac.nz

What you need to know

  • Heart failure should be considered in patients presenting with shortness of breath in primary care

  • B-type natriuretic peptide (BNP) is an important initial test for heart failure, and a negative result usefully excludes heart failure.

  • Heart failure includes a variety of causes, many of which have specific treatments

Heart failure is prevalent worldwide, affects quality of life, and is associated with high morbidity and mortality. Global prevalence estimates suggest that 1-2% of adults in developed countries have known heart failure.12 In the UK alone, around one million people are diagnosed with heart failure, creating a huge demand for specialist cardiology services.3 Heart failure often occurs in primary care, where many patients have risk factors and usually require long-term treatment even after symptoms improve. This update focuses on recent evidence and changes in heart failure clinical practice guidelines, highlighting the aspects most relevant to primary care.

Stages and classes of heart failure

A universal definition and new classification system for heart failure was proposed in 2021 by the Heart Failure Society of America (HFSA), the Heart Failure Society of the European College of Cardiology (HFA-ESC), and the Japan Heart Failure Society (JHFS). This system is incorporated into recent American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Failure Association of America (HFSA) guidelines.FourFive This four-stage classification system is divided into two asymptomatic pre-heart failure stages (Stage A “At Risk” and B “Pre-Heart Failure”) and two symptomatic stages that include the clinical syndrome of heart failure (Stage C ” Symptomatic” and D). “Advanced”) (Box 1).FourFive Most guideline-based drug treatments are targeted at stages C and D, but may also be indicated in asymptomatic patients to reduce the risk of progression to symptomatic heart failure. The New York Heart Association (NYHA) functional classification system complements this staging system and applies to stage C.

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