Figure 1. Natural History of HF defines advanced HF.

The stages in the natural history of HF clarify the relationship between cardiovascular disease (Stage A), asymptomatic abnormalities in cardiac structure and function (Stage B), overt symptomatic HF (Stage C) and advanced HF (Stage D). The natural history of over HF is further characterized in the insert where the fluctuating but progressive clinical course after HF presentation and commencement of optimal medical therapy (OMT) or later, with cardiac resynchronization therapy (CRT) or advanced HF therapies such as cardiac transplantation or ventricular assist devices (LVAD) is shown. Progression to poorer functional status associated with higher risk of hospitalization and overall health care resource utilization occurs over time. The potential modes of death over the course of the natural history of HF are emphasized where patients may die of non-HF related cardiovascular or non-cardiovascular causes (non-HF death, NHFD) or sudden cardiac death (SCD) at any time with the risk of SCD increasing as HF worsens. Patients who avoid NHFD or SCD die of progressive HF (HF).