Metra et al proposed a definition for advanced chronic heart failure (ACHF) which incorporates current understanding of the disorder. The authors are from the Study Group on Advanced Heart Failure of the Heart Failure Association of the European Society of Cardiology.


Criteria for advanced chronic heart failure:

(1) NYHA functional class III or IV

(2) episodes of fluid retention and/or peripheral hypoperfusion at rest

(3) one or more manifestations of severe cardiac dysfunction:

(3a) LVEF < 30%

(3b) a severe abnormality of cardiac function on Doppler echocardiography with a pseudonormal or restrictive mitral inflow pattern

(3c) high left ventricular filling pressures

(3d) elevated serum BNP or pro-BNP in the absence of non-cardiac explanations

(4) one or more findings indicative of severe impairment of functional capacity:

(4a) inability to exercise

(4b) 6 minute walking test (6MWT) less than 300 meters (a lower threshold may be used on females or patients >= 75 years)

(4c) peak VO2 < 12 mL per kg per min (some may use < 14 mL per kg per min)

(5) history of one or more hospitalizations for heart failure in the past 6 months

(6) symptomatic despite optimized therapy



• NYHA class III or IV is associated with severe symptoms of heart failure with dyspnea and/or fatigue at rest or after minimal exertion.

• Episodes of fluid retention may include pulmonary edema, peripheral edema or systemic congestion.

• High left ventricular filling pressures are indicated by PCWP > 16 mm Hg and/or mean right atrial pressure > 12 mm Hg by pulmonary artery catheterisation

• Optimized therapy may include use of diuretics, inhibitors of the renin-angiotensin-aldosterone system, beta-blockers and cardiac resynchronisation therapy (CRT).


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