Matters of the heart: failing better

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Reflecting the increasingly successful management of a range of cardiovascular conditions, notably acute myocardial infarction and hypertension, and the shifting demography towards a relatively aged population, we are seeing an increase in the incidence of heart failure, which is now equivalent to that of the four most common cancers combined [1]. This improved survivorship, the living legacy of innovative clinical medicine and public health initiatives, should be celebrated, but also demands of us a duty to accurately diagnose and optimize the care of the burgeoning clinical population endowed with this diagnosis. The very definition of heart failure has also become more nuanced, with the description of a trio of heart failure variants based on cardiac imaging and assessment of the left ventricular ejection fraction, that percentage of blood volume in the relaxed diastolic ventricle ejected during systolic contraction, normally about 55%. These constitute heart failure with a reduced ejection fraction of less than 40% (HFrEF), heart failure with a preserved ejection fraction of at least 50% (HFpEF), and the difficult middle child, heart failure with a mid-range ejection fraction of 40–49% (HFmrEF) [2]. In people with clinical features of heart failure, HFrEF and HFpEF constitute 80–90% of cases and are evenly represented, HFmrEF accounts for the residual 10–20% [3].
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