DENOLIN, H.

KRAYENBUEHL, H.

KUHN, H.

LOOGEN, F.

REALE, A.

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European Heart Journal (1983) 4, 445--M8The definition of heart failureH. DENOLIN,* H. KuHN.f H. P. KRAYENBUEHL,^: F. LooGEN.f AND A. REALE§Although everybody feels they know what heartfailure means, there is no generally accepteddefinition. The following opinions and definitionsdescribe the conflicting situation: 'It should beobvious that the diagnosis of cardiac failure, likethat of many other diseases, depends upon itsdefinition, which varies with different auth-orities'!1]. 'Since no single measurement discrimi-nates between the normal and failing heart, nodefinition of heart failure is universally accepted!2!.'We have yet to wait for a reliable and reproducibletest that will tell us if a heart is good or bad'!3). 'Todate virtually all studies of congestive heart failurehave been hampered by the lack of consistent diag-nostic criteria and comprehensive follow-up evalu-ation'M. 'For the present, heart failure may bedefined as the pathologic condition in which anabnormality of cardiac muscle function is respon-sible for the inability of the heart to pump bloodat a level adequate to meet metabolic tissuedemands!5). 'Heart failure is the pathophysiologicstate in which an abnormality 01 cardiac functionis responsible forfhe failure of the heart to pumpblood at a rale rpTrnmsiiratf W'7K th<* p*q"'f*-ments of the metabpiiyinft t)'ssnes3?l. 'Heart failureis the abnormal condition in which disturbed car-diac performance is primarily responsible for theinability of the heart to pump blood at a ratecommensurate with systemic metabolic require-ments't7). 'In practice, heart failure is best describedin terms of its two primary sets of clinical manifes-tations, pulmonary congestion and peripheralhypoperfusionW. 'Cardiac failure (Herzinsuffi-zienz) means insufficient cardiac output; i.e. at restor at exercise abnormal myocardial function (e.g.abnormal increase of ventricular filling pressureand/or of end-diastolic ventricular volume) may bepresent in spite of normal cardiac output (i.e.without cardiac failure)!9!.Received for publication 30 July 1982; and in revised form 1October 1982.•University of Brussels, Belgium.tMedical Hospital B, University of Dusseldorf, West Germany.^Medical Policlinic, University of Zurich, Switzerland.§Policlinico Umberto I, University of Rome, Italy.Thus, the main problem in defining heart failurearises from the fact that a large number of differentdefinitions seem to be necessary for a detaileddescription of all the conditions and viewpointswhich are referred to heart failure.Since we feel that one has clearly to distinguishbetween the normal state, an abnormal state of theheart and heart disease, and since we feel not onlythat the output of the heart is important but alsohow the cardiac output is delivered to the tissues,a new definition seems to be mandatory. For ageneral use, the following definition is suggested:Heart failure is the state of any heart disease inwhich, despite adequate ventricular filling, theheart's output is decreased or in which the heart isunable to pump blood at a rate adequate for satisfy-ing the requirements of the tissues with functionparameters remaining within normal limits.This definition is applicable for all clinically usedsubsets of heart failure such as latent, congestive,overt and low output heart failure. Latent heartfailure is then defined as a state in any heart diseasein which the heart is unable to pump blood at a rateadequate for satisfying the requirements of the tis-sues during stress with function parameters remain-ing within normal limits, i.e. this definition impliesthat although the heart may be able to satisfy therequirements of the tissues during stress, thefunction parameters do not remain within normallimits. In all other subsets of heart failure, irrespec-tive of whether cardiac output is normal ordepressed, function parameters at rest are notwithin normal limits.In the suggested definition the term 'functionparameters' means all features characterizing theactivity of the heart as a pump and/or as a muscle.From this definition of heart failure it becomesevident that heart failure is not solely defined bycommonly used criteria, i.e. cardiac output and themetabolism of the tissues.References[1] Sokolow M, Mcllroy MB. Clinical cardiology. SantaMonica, Calif: Langc Medical, 1979.0195-668X/83/07O445 + O4 S02.00/0 O 1983 The European Society of Cardiology446 H. Denolin et al.[2] Wagner S, Cohn K. Heart failure: a proposed defini- [6] Braunwald E. Heart failure on overview. In: Fishmantion and classification. Arch Int Med 1977; 137:675. AP, ed. Heart failure. New York: McGraw-Hill, 1978.P] Editorial. Pump failure. Br Med J 1977; 2: 1430. [7] Mason DT. Congestive heart failure. New York: York[4] McK.ee PA, Castelli WP, McNamara PM, Kannell Medical Books, 1976: 1.WB. The natural history of congestive heart failure: [8] Forrester JS, Waters DD. Hospital treatment ofthe Framingham study. N Engl J Med 1971; 285: congestive heart failure. Management according to1441-6. hemodynamic profile. Am J Med 1978; 65: 173-80.[5] Gold H1C Heart failure—physiological and patho- [9] Reindell H, Roskamm H. Herzkrankheiten. Berlin:physiological concepts. In: Willerson JT, Sanders CA, Springer 1977: 373.eds. Clinical cardiology. New York; Grune andStratton, 1977: 63.Editor's CommentOMNIS DE SCRUTIO PERECULOSA EST (Every definition is dangerous)— ERASMUSOur distinguished colleagues are to be admired both for their courage and for their caution in denningheart failure. We have already had problems with definitions in the European Heart Journal, partlybecause of a misunderstanding of the use of the word 'definition'. In standard English, 'definition' hastwo quite separate meanings — one, the meaning of a word, and the other, the fundamental nature ofa thing. Clearly, Professors Denolin, Kuhn, Krayenbuehl, Loogen and Reale are addressing themselvesto the first concept of definition, and it is this concept that it is hoped that further contributors to theJournal will address.Whether an agreed definition of heart failure will be achieved remains to be seen. The Editor hopesthat his vanity will be excused if he quotes himself:'Failure in anything implies expectations unfulfilled, and one's definition of heart failure depends uponwhat one expects of the heart. No single definition suffices because the clinical and physiological criterianecessarily differ. The clinician regards his patients as having heart failure when there are symptomsor physical signs attributable to inadequate cardiac performance. The physiologist regards the heartas failing when the contractility of the ventricles or the cardiac output fall outside the statistically definednormal range 'I'lIn the Editor's view, definitions are extremely useful in ensuring that two parties in a controversy ordiscussion are talking about the same thing, but they pose difficulties when the same term changes itsmeaning depending upon the context in which it is used. Furthermore, the definition of a word or phrasechanges with the passage of time, both because of greater understanding and because of natural changesin linguistic usage. He therefore feels that more than one definition of 'heart failure' should be agreeddepending on the specific contexts in which the term is used but that these definitions should be subjectto periodical review.Reference[1) Julian DG. Cardiology, 4th Ed. Bailliere Tindall, London, 1983: 9.Comment by E. Braunwald (Boston, MA, USA)In the opening paragraph of his classic text, Diseases of the Heart, published in 1933, Sir Thomas Lewisstated: 'The very essence of cardiovascular practice is recognition of early heart failure'!'!. How correcthe was! Heart failure occurs as the consequence of many forms of heart disease, and in the United Statesalone afflicts at least 4 million individuals of all ages. In its chronic form, heart failure is generally associ-ated with a poor prognosis, and it is one of the most common of all causes of death. It causes much per-sonal suffering and places enormous economic burdens on the patient, his family, and on society at target2!.Despite the central role of heart failure in cardiology, this syndrome remains poorly defined a half cen-tury after Lewis; hence the need for a definition, which is clearly provided by Professor Denolin and hisdistinguished colleagues. As they indicate, my definition of heart failure is that it is 'the pathophysiologicstate in which an abnormality of cardiac function is responsible for failure of the heart to pump bloodThe definition of heart failure 447at a rate commensurate with the requirements of the metabolizing tissues'. Implicit in this definition arefundamental differences between failure of the myocardium, heart and circulation. Myocardial failurealways produces heart failure, but the converse is not necessarily the case, since a number of conditionsin which the heart is suddenly overloaded (e.g. acute aortic regurgitation secondary to infective endocar-ditis) can produce heart failure in the presence of normal myocardial function. Also, conditions such astricuspid stenosis and constrictive pericarditis, which interfere with cardiac filling, can produce heart fail-ure without myocardial failure. Heart failure, in turn, always produces circulatory failure, but again theconverse is not always true, since a variety of noncardiac conditions, e.g. hypovolemic shock or extremelysevere anemia, beriberi, and other high-output states can produce circulatory failure at a time whencardiac function is normal or only modestly impaired!3).It is useful to have a working definition of heart failure since recent advances in cardiac physiology,pharmacology and surgery make it likely that we are now at the threshold of major advances in thediagnosis and treatment of this extremely important condition!4!.References[1] Lewis T. Diseases of the heart. New York, The MacMillan Co, 1937: 1.P] Braunwald E. Historial overview and pathophysiologic considerations. In: Braunwald E, Mock MB, Watson JT,eds. Congestive Heart Failure. Grune and Stratton, New York, 1982: 3.[3] Braunwald E. Pathophysiology of heart failure. In Heart Disease, 2nd Ed. Philadelphia, W. B. Saunders, 1983:447.[4] Braunwald E, Mock MM, Watson JT. Congestive heart failure: A propitious time for intensified research. Am JCardiol 1983; 51: 603.Comment by D. G. Gibson (London)HEART FAILURE—AN OBSOLETE TERM?The idea of'heart failure' is an important one for cardiologists. They document its presence, seek to pre-vent its occurrence and treat it with a variety of drugs notable for their potency and their incidence ofside effects. It is thus distressing that no satisfactory definition of 'heart failure' has hitherto been pro-pounded; the efforts of your contributors to provide one will thus be seen as correspondingly laudable,and the results of their deliberations studied with interest. Taking into account their last paragraph, itmay be stated as follows: Heart failure is the state of any heart disease in which(1) the heart's output is decreased, or(2) function parameters are outside normal limits even though cardiac output is normal for tissuerequirements.This definition seems to me to have a number of limitations which will make it unsuitable for clinicaluse. Disregarding the use of the unsatisfactory term 'parameter', the definition of 'function parameters'itself is not clear. The authors suggest that it means 'all features characterizing the activity of the heartas a muscle and/or pump', but this is scarcely a rigorous definition. Would the authors take an increasein septal thickness, for example, to be such an abnormality? I suspect not, but what about an increasein left ventricular mass, which would make a diagnosis of left ventricular hypertrophy synonymous withheart failure? Other problems arise when diastolic disturbances are considered. Whereas a reduction inthe rate of ventricular relaxation would clearly fit in with their definition, does the same apply to thepassive stiffness of the ventricle, which is independent of whether or not the heart shows any activity asa muscle or a pump? The definition also depends critically on these functional parameters being withinnormal limits, but gives no indication as to how these limits are to be defined. Are 95% confidence limitsto be used? If this is the case, 5% of a normal population will have values outside them, and if manyseparate 'parameters' are measured, the chances of any normal subject fulfilling the criteria for 'heart fail-ure' will be greatly increased. The definition as it stands includes values on either side of the normal range.Are we to believe that an abnormally high value of ejection fraction, for example, constitutes evidenceof heart failure? The definition also includes 'any' heart disease, and so would presumably encompassmitral stenosis, supraventricular tachycardia, or constrictive pericarditis. When combined with theauthors' views on the significance of any departure from normal of a function parameter, this leads to448 H. Denolin et al.further complications. A measurable diastolic gradient across the mitral valve or a positive systolic gradi-ent across the aortic valve in the second half of ejection are both very abnormal, and are both functionparameters in the sense used in the definition. Any patient with more than the mildest mitral or aorticstenosis would thus be categorised as being in heart failure. The same applies for mild valvular regurgi-tation, using an increase in end-diastolic volume as the criterion. It appears, therefore, that any patientwith any measurable cardiac abnormality under any circumstances, along with a significant proportionof normal subjects, hypertensives of any severity, and subjects in whom ventricular function measurementsare unusually good will be regarded, on the suggested criteria, as being in heart failure. I do not believethat such a definition will have any clinical, epidemiological, or theoretical value.The term 'heart failure' is primarily a clinical one, and dates from an earlier era of medicine. The prob-lem arises when its use must be reconciled with the results of physical measurements of pressure, volume,or flow, quantities that can be defined rigorously in terms of simple Newtonian physics. Heart failurehas never been defined in this way, so that its meaning must be established indirectly. The authors haveattempted to do this by examining its definition from a number of sources, and demonstrated their incom-patibility with one another. However, if one wishes to establish what a group of individuals mean by aword, it is often more rewarding to watch the way they use it rather than asking them to define it. Thisapplies as much to medical authors as to any other group. Although the definitions given by the variousauthorities cited differ, their clinical accounts of the entity they deem to be heart failure are remarkablyuniform. It is a condition associated with symptoms and signs. We are on familiar ground when we readof breathlessness on exertion, nocturnal dyspnoea or fatigue. On examination we find peripheral oedema,elevation of the venous pressure, or gallop rhythm. It is this clinical syndrome that most of us call tomind when heart failure is mentioned rather than a single abnormality of some function parameter. Amajor component of this symptomatology is due to abnormal renal function, whose cause is not clearlyunderstood, but which cannot easily be related to the adequacy or otherwise of its blood flow or metab-olism, another of the suggested criteria. It might be questioned whether it is worth while even attemptingto define heart failure in more rigorous terms, or whether the term should be allowed to lapse, as hashappened with others, such as 'the vapours'. I think that it should be preserved, provided that its limi-tations are accepted, since it embodies a clinical approach older and more complex than that of assessingpatients by simply comparing function parameters with presumed normality. The idea of'failure' of anorgan is a pervasive one in clinical medicine. It can be applied to kidney, liver, and lungs as well as tothe heart. It includes the concept of a final common pathway in the clinical course, which is independentof the original aetiology of the disease; it is a definite and advanced step in the natural history of thecondition, with characteristic clinical features and therapeutic consequences. If treatment is successful,it may be possible to make the evidence of'failure' regress, although the underlying disease remains pre-sent. Unlike a simple anatomical or physiological diagnosis, therefore, a patient can go 'in' and 'out' offailure. Function is often held to be in some sense 'compensated' until its onset. Whether such a quantumstep in the natural history of heart disease can be defined on a clear physical basis is uncertain. Starlingl'lsuggested that it might represent the stage at which one of the major homeostatic mechanisms wasexhausted; such an approach is clearly defined and could be re-examined in the light of control systemtheory. If such a stage could, indeed, be identified, then it might be appropriate to equate it with the ideaof heart failure as elaborated clinically. -However, I do not believe that this is yet possible. It may wellbecome so, since one neglects clinical information at one's peril, but until it does, I think it is more valu-able to regard the term 'heart failure' as a useful clinical description only. It should certainly not beregarded either as a diagnosis or as a single clinical entity; rather its appearance should be seen as a chal-lenge to determine the nature of unique haemodynamic disturbance present in the individual patient, sothat optimum treatment can be given.Reference[1] Patterson SW, Piper H, Starling EH. The regulation of the heart beat. J Physiol 1914; 48: 465-573.

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