Publisher: Nova Science. www.novapublishers.com, New York, USA
EDITORIAL BOARD OF The World Heart Journal (WHJ).
Founding Editor
Dr Franz Halberg, MD(USA), Professor of Chronobiology, Halberg Chronobiology Center, Department of Pathology and Laboratory Medicine, University of Minnesota, Minneapolis, Minn, USA (On heavenly abode from  2013) (5 July 1919 – 9 June 2013)

Co-Editors in Chief:
Dr Germaine Cornelissen, PhD(USA), Professor,  Integrative Biology and Physiology, co-Director, Halberg Chronobiology Center, University of Minnesota, Minneapolis, MN, USA, corne001@umn.edu
Dr R B Singh, MBBS,MD(Intern Med-Cardiol), Professor Internal Medicine, Halberg Hospital and Research Institute, Moradabad (UP)244001, India, (rbs@tsimtsoum.net)
Submission: Please send your manuscript by email attachment to Co-editors)
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Editors:
Dr Krasimira Hristova, MD, PhD, Cardiologist, Department of Cardiology, National University Hospital, Sofia,
Bulgaria, khristovabg@yahoo.com
Dr Jan Fedacko, MD (Slovakia), Assistant Professor, Department of Internal Medicine, PJ Safaric University,
Kosice, Slovakia, Janfedacko@hotmail.com
Dr Galal Eldin Nagib-Elkilany, MD, PhD, Department of Cardiology, Gulf Medical University, Ajman, UAE
<galal.elkilany@gmail.com>
Associate Editors.
Dr Jaipaul Singh, PhD, DSc
School of Forensic and Applied Sciences, University of Central Lancashire, Preston, Lancashire, England, United
Kingdom ( jsingh3@uclan.ac.uk );
Dr Chee-Oon Kong, MD(Taiwan), Professor of Medicine, National Yang-Ming University, Taipei, Taiwan,
cwkong@vghtpe.gov.tw
Dr Sergey Chibisov,MD,PhD, Professor of Physiopathology, People,s Friendship University of Russia, Moscow,
Russia sshastun@mail.ru
Assistant Editors:
Tsui-Lieh Hsu,MD, Taiwan Society of Cardiology, Taipei, Taiwan, tlhsu@vghtpe.gov.tw
Dr Eri Toda, Department of Cardiology, Tokai University Hachioji Hospital, Tokyo, Japan
eritoda@is.icc.u-tokai.ac.jp
Dr Toru Takahashi, PhD, Department of Nutrition, Graduate School of Human Environment Science,
Fukuoka Women’s University, Fukuoka, Japan, takahashi@fwu.ac.jp
Dr Sherif Baathallah MD , \ RAK Hospital ,Fujairah, UAE
Dr Abdulla Shehab, MD,PhD, UAE University, UAE.
Managing Editors: Ms Maya Columbus(Publication);Dr R B Singh(Responsibility of contents)
Editoial Secretaries:
Dr Rajeev Gupta, MD, DM, MRCP, Consultant Cardiologist, Kalba Hospital, Kalba, UAE.
M:0097150-8324901​,rajeevsavita.gupta@gmail.com
MEMBERS OF THE EDITORIAL BOARD:
Dr Hideki Mori, MD,FICC, Aomori Prefectural Central Hospital, Aomori City, Japan.
Dr Fabien Meester(Belgium), The Executive Director, The Tsim Tsoum Institute, Krakow, Poland,
fdm@tsimtsoum.net
Dr Brian Tomlinson, MD(Hong Kong), Professor of Internal Medicine, The Chinese University of Hong Kong,
Shatin, Hong Kong., btomlinson@cuhk.edu.hk
Dr T K Basu, PhD(Canada), University of Alberta, Edmonton, Canada, Tapan.Basu@ualberta.com
Dr Rakesh Sharma, PhD(USA),Department of MRI Imaging, Florida University, Florida, USA
rksz2009@gmail.com
Dr M L Garg, PhD(Australia), Professor ,School of Biomedical Sciences and Pharmacy, The University of
Newcastle, Australia. , Manohar.Garg@newcastle.edu.au Dr Hilton Chaves, MD,PhD,
Professor, Division of Cardiology, Department of Internal Medicine, Federal University of Pernambuco, Recefe,
Brazil, hchavesjr@gmail.com Dr Jong Lee, MD, PhD, Department of Medicine, University of Minnesota
Medical School, Minneapolis, USA
Dr Borislav Demitrov, MD, PhD,
Academic Unit of Primary Care, and Population Sciences, University of Southampton, UK, b.demitrov@soton.ac.uk
Branislav Milovanovic,MD,PhD
Neurocardiological Laboratory, Department of Cardiology,University Clinical Center Bezanijska Kosa, Medical
Faculty,University of Belgrade, Serbia, branislav_milovanovic@vektor.net
Dr Jaipaul Singh, PhD, DSc
School of Forensic and Applied Sciences, University of Central Lancashire, Preston, Lancashire, England, United
Kingdom ( jsingh3@uclan.ac.uk );

Hisham Mohd Aboul-Enein, MD, Benha University Vice President, Cairo, Egypt,haenin@yahoo.com
Chee Jeong Kim, MD, Professor, Division of Cardiology, College of Medicine, Chung-Ang University, Seoul,
Korea, cjkim@cau.ac.kr
Dr Elliot Berry,MD(Israel),
Department of Human Nutrition and Metabolism, Braun School of Public Health, Hebrew University-Hadassah
Medical School, Jerusalem, Israel.
Dr Gal Dubnov,MD,
Department of Human Nutrition and Metabolism, Braun School of Public Health, Hebrew University-Hadassah
Medical School, Jerusalem, Israel.
Dr C Chaithiraphan, MD, President Chaophya Hospital, Director of Cardiac Center, Bankok, Thailand
Dr Rody G Sy,MD, Cardinal Santos Medical Center, Metro Manila (Philippines),
Dr Kaumudi Joshipura,DSc, Department of Epidemiology, Harvard School of Public Health, Boston, USA,
kjoshipu@hsph.harvard.edu (USA),
Dr C E Chiang,MD, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital and
National Yang-Ming University School of Medicine, Taipei, Taiwan, cechiang@vghtpe.gov.tw
Dr Antonis Zampelas, PhD, Professor in Human Nutrition, Agricultual University of Athens, Athens, Greece.
Dr H R Gundurao, PhD, Department of Pathology and Lab. Medicine, University of Minnesota Medical School <
Minneapolis, USA.
Dr C M Yu, MD, Division of Cardiology, Chinese University of Hong Kong, Hong Kong. medt@cuhk.edu.hk
Dr M L Burr, MD(UK), Centre for Applied Public Health Medicine, University of Wales College of Medicine,
Temple of Peace and Health, Cathays Park, Cardiff, CFl 3NW, UK.
Dr Agnieszka Wilczynska, PhD, Department of Psychology, University of Silesia, Katowice, Poland
Dr Adarsh Kumar, MD,DM, Professor of Cardiology, Department of Internal Medicine, Government Medical
College, Amritsar, India.
Dr Kuniaki Otsuka, MD,PhD
Professor emeritus of Tokyo Women's Medical University, and Professor of Department of Chronomics and
Gerontology,Tokyo Women's Medical Universoty, Arakawa, Tokyo, Japan 116-856781-3-3810-1111, Tokyo,
Japan, Email: otsukagm@dnh.twmu.ac.jp
Dr Daniel Pella, MD(Slovakia),Department of Internal Medicine, PJ Safaric University, Kosice, Slovakia.,
daniel.pella@upjs.sk
Dr NS Neki,MD,FRCP, Department of Medicine, Government Medical College, Amritsar, India
Editorial Advisers:
Dr Liu Lisheng, MD, Professor of Cardiology, Cardiovascular Institute and Fu Wai Hospital, Beijing, China.
Dr Akira Yamamoto, MD (Japan), Professor of Internal Medicine and Founder, Asian Pacific Society of
Atherosclerosis and Vascular Diseases, Osaka, Japan
Dr E D Janus, MD(Australia), Founder Secretary General, Asian Pacific Society of Atherosclerosis and Vascular
Diseases, Australia.
Dr Dr Rodolfo Paoletti, MD(Italy), Professor of Pharmacology, Institute of Pharmacology, Milan, Italy.
Dr Jim Shepherd(UK), Editor, Atherosclerosis, UK
Dr NS Dhalla, MD (Hon), DSc, Professor of Cardiovascular Sciences, St Boniface Hospital Institute of
Cardiovascular Sciences, Winnipeg, Canada, nsdhalla.@sbrc.ca
Statistical Editor: Prof .Dr Douglas W Wilson,PhD, DSc (UK), Chronobiology and Statistics,, Formerly, School of
Medicine, Pharmacy and Health, Durham University, Durham, UK, d.w.wilson@durham.ac.uk
REFREES: VOLUNTEERS.
Dr Shashank Joshi, MD,DM, Mumbai, India; shashank.sr@gmail.com
Rohan Khera, MD, Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine,The
University of Iowa, USA, email:  rohan-khera@uiowa.edu  OR  rohankhera@outlook.com , Dr Neha Singh, PhD,
David Geffen School of Medicine at UCLA, Los Angeles, California, senger.neha@gmail.com

Sponsors.
BIOCOS Group (USA),
International College of Cardiology (Slovakia), and
International College of Nutrition (India).

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WORLD HEART JOURNAL
PUBLISHERS:
Maya Columbus
Nova Science Publishers, Inc.
400 Oser Avenue, Suite 1600
Hauppauge, NY 11788
Tel: 631- 231-7269, Fax: 631-231-8175
email: novaeditorial@earthlink.net, novascience@earthlink.net ,
maya1nova@earthlink.net
Web: www.novapublishers.com

SCOPE:
There are hardly 10 good journals of Cardiology, which cater several million cardiovascular scientists and
physicians.A lot of material is either not published or published in substandard manner.The scope would depend
upon the components and contents of the journal which in turn would depend upon the authors.There may be 4-6
issues in a year in the beginning but would depend on submissions.
AUDIENCE:Libraries,individual scientists and treating doctors,researchers and teachers,health workers who would
like to buy the journal, including 600 members,each of the Int Coll of Nutrition and  of the International College of
Cardiology and the BIOCOS group.
REPRINTING IN INDIA:The journal may be reprinted in a developing country to decrease its cost and enhance
circulation like BMJ-India or JAMA-India
SPONSORSHIP OF INDUSTRY:Open to all advertisers to decrease the cost.Members of the editorial board may
influence the Pharmaceutical companies and instrument manufacturers as well as chemical and kits suppliers to buy
the journals in bulk, for free distribution to their clients
To enhance the goodwill of their company.Members of the editorial board,refrees and authors are
Encouraged to contact the industry and write to the publisher/editor,who would be gifted by us.
COMPONENTS of WHJ:

1.Editorials and Commentaries(1-3pages with 5-15 references);4-6 in each issue.
2.Cardiovascular News.100-500 words on any area of CVD.
3.Clinical Reviews.2-3 each issue;10-20pages(Mini reviews-10 pages,50 references) with not more than 100
references,10% references,> 2 years old for all the components of WHJ.
4.Contributions from Future Cardiologists(2-3 each issue); Experiences of the residents and PhD scholars,related to
CVD;2-3 pages with 5 references.
5.Original Research Articles.5-10 articles each issue with 5-10 pages with references,not more than 50.
6.Brief Reports:Papers on cases ,case reports with less scientific but acceptable methods.2pages,<10 references.
7.World Heart Forum:Letters to the editor on articles published in any indexed journal of the world and any
interesting brief report not exceeding one page.Criticism of the policy makers of each country especially western
world because the whole world follows the west.- one page,5 references.
6.Novascience Highlights:News from the Novascience Publications.
7.Pharma Heart Forum:Injustice done with Pharma companies and Pharma companies doing unethical practices
would be highlighted by impartial experts,preferably from experts of pharmaceutical and instrument manufacturing
companies to give them voice for benefit of the peoples heart health.
8.Calendar of Conferences.
SECTIONS, TO BE COVERED IN THE WHJ:
1.Epidemiology and Prevention.
2.Chronocardiology and Chronomics.
3.Nutrition and Lifestyle in CVD.
4.Clinical Cardiology.
5.Cardiovascular Sciences( Molecular Cardiology:biochemistry and biology).
6.Hypertension.
7.Coronary artery disease.
8.Pharmacotherapy.
9.Electrophysiology
10.Echocardiography.
11.Nuclear Cardiology.
12.Pediatric Cardiology.
13.Geriatric Cardiology.
14.CVD in women.
15.Cardiac Rehabilitation and prehabilitation.
16.Interventional Cardiology.
17.Cardiac surgery.
INSTRUCTIONS TO AUTHORS:
World Heart Journal is the publication of Novascience Publishers Inc.NY,USA.The journal would consider
publication of manuscripts for its various sections,pertaining to cardiovascular diseases.
Manuscripts should be addressed to Professor R B Singh,Editor,World Heart Journal,Address of the Publishers,and
via email to:Managing Editor, maya1nova@earthlink.net
Editorial Policy:
The WHJ disapproves the submission of same article simultaneously to different journals for consideration as well
as duplicate publication.Opinions expressed in the articles published in the WHJ,are those of the authors and not
necessarily of the editor.Neither the editors,nor the publisher guarantees,warrants or endorses any product or service
advertised in the journal.The accepted papers,would be edited,without altering the meaning to improve clarity and
sense.Every manuscript submitted to WHJ,would be scrutinized,by two or more refrees,
Corresponding Author would be given e-print of one PDF file free of charge for academic purpose only not
for commercial use.
Guidelines for Manuscript Submission:
The manuscript should be prepared, in accordance with the uniform requirements for manuscripts submitted to
biomedical journals, compiled by the International Committee of Medical Journal Editors(N Engl J
Med,1997,336:309-315.).
We need three complete sets of manuscripts, typed in double space, on one side of the page, throughout.The
manuscript should be arranged inorder;Covering letter,title page with authors and their affiliations, abstract
structured,introduction,methods,results, discussion,acknowledgements,references,tables and legends to
illustrations.Three sets of illustrations in three separate envelope,should be attached at the end. The pages of the

manuscript should be numbered consequitively,beginning with the title page. Alternatively send manuscript in two
files as email attachment; 1. Text with references 2. Figures and Tables.
Covering Letter.
All authors or corresponding author on behalf of all, should take the responsibility of signing the covering letter,
indicating that all agree with the contents ,and all have participated in the study or in the writing of manuscript and
the article is entirely submitted to WHJ.
Acceptance of the manuscript for publication in the WHJ ,implies transfer of copyright to the publisher.
References:
A full list of references should be included at the end of the article.The references should conform to the Vancouver
style and should be numbered,consecutively in the order,in which they first appear in the text.These should be given
in parentheses( ).References cited only in the tables should be numbered in accordance with a sequence established
by the first identification in the text of a particular table or illustration.Personal communications,unpublished articles
should not be cited as references,though these may be mentioned in the text in parentheses.Abstract should not be
used as references unless,it is very important.
Examples:
1.Articles in Journals.Authors surname followed by first and middle name initials,title of paper,name of journal,year
of publication,volume,page number of beginning-and last page of the article.Include the names of all authors,if there
are 5 or less.If six or more,the first 3 followed by et al.The title of the journal should be abbreviated according to the
style, used in the Index Medicus. e.g Singh RB,Cornelissen G,Weydahl A et al.Circadian heart rate and blood
pressure variability
Considered for research and patient care.Int J Cardiology 2003,87:9-28.
2.Articles in books.Authors,title,edition,publisher,city,year,pages.
eg.Singh RB,Rastogi SS.Nutritional Aspects of Hypertension.International College of
Nutrition,Moradabad,India,1989,p-
3.Chapter in book.Authors,chapter title,book title,edition,editors,publishers,city,year,pages.e g
Otsuka K,Shobgo M,Kozo M et al.Chronomes,aging and disease.Ecological Destruction,Health and
Development:Advancing Asian Paradigms.Furukawa H,Nishibuchi M,Kono Y,Kaida Y(eds),Kyoto University
Press,Japan 2004,p367-394.
Future Publications. Journal of the International College of Cardiology (JICC)
Publisher, JICC, Open Access, Quarterly.
Dr Mahmood Moshiri MD,APATH,CPATH,DTNH,RNCP,FICN
International College of Cardiology, Phone: 416-450-6414 
28 Macdonald Crt,, Richmond Hill, Ontario, L4E 1E0, Canada.,Phone: + 416 450 6414
Email: moshiri@nextpharmainc.com
Editor in Chief: Prof Dr Ram B Singh,MD, FICN, FICC, FIACS, rbs@tsimtsoum.net
The Six Stages of Heart Failure
Editorial
THE SIX STAGES OF CHRONIC HEART FAILURE.
Ram B Singh, Galal Elkilany, Jan Fedacko, Krasimira Hristova. Editors.
When you are sorrowful look again in your heart, and you shall see that in truth you are weeping for that
which has been your delight. “ Kahlil Gibran -Joy and Sorrow.
The exact cause and cure, classes and stages for chronic heart failure(CHF) are not yet
established [1-3]. Therefore, CHF remains a leading cause of morbidity and mortality globally.
There is an urgent need to highlight basic primary risk factors of CHF, such as western diet,
sedentary behavior and obesity, sleep disorders, emotional disorders, tobacco and alcoholism
which are known to cause early changes of cardiac dysfunction [4,5]. These behavioral factors

are also the causes of hypertension, coronary artery diseases (CAD), diabetes mellitus, that are
major risk factors of CHF. Speckle tracking echocardiography(STE) using 2D and 3D
echocardiograph has demonstrated abnormalities in global longitudinal strain and area strain
indicating pre-heart failure (PHF) in patients with risk factors of CHF [2]. There is an unmet
need to conduct such STE studies among apparently healthy subjects who are exposed to
behavioral risk factors of CHF as well as biological risk factors of HF, for early diagnosis and
prevention [2,4].
The 2022 HF guideline provides recommendations based on contemporary evidence for the
treatment of these patients [4]. The recommendations present an evidence-based approach to
managing patients with HF, with the intent to improve quality of care and align with patients’
interests. Many recommendations from the earlier HF guidelines have been updated with new
evidence, and new recommendations have been created when supported by published data. Value
statements are provided for certain treatments with high-quality published economic analyses.
Despite these guidelines, HF would continue to be serious public health problem because there is
little attempt to diagnose HF in early stages [1-5].
Left Ventricular Twist as Function of the Heart
The pathophysiology of cardiac dysfunction and CHF is very complex [6-9]. It begins with
physiological twist dysfunction, later developing in to sub-endocardial dysfunction, resulting in
to cardiac dysfunction due to underlying neuro-hormonal dysfunction. It seems that factors that
influence the neuro-hormones and the heart such as obesity, myocardial infarction could be
important determinant of the development of cardiac dysfunction [5,10,11]. Richard Lower
FRCP (1631–1691) was the first to publish the twisting motion of the LV, in 1669, as “the
wringing of a linen cloth to squeeze out the water”, which continues to intrigue the experts in
their quest to understand cardiac function [8]. Apart from STE and magnetic resonance imaging
(MRI) may be used to examine LV twist [10-12]. It appears to be crucial to examine twist
function of the heart which would require quantification of the LV twist. The cardiac twist or
torsion represents the mean longitudinal gradient of the net difference in the clockwise and
counterclockwise rotation of the apex and base of the LV, as viewed from the apex of the left
ventricle [1-3]. The LV twist deforms the sub-endocardial fiber matrix, resulting in the storage of
potential energy. A further deformation in the recoil of twist may cause the release of restoring
forces, which contributes to diastolic relaxation of the LV with early diastolic filling [12].
Interestingly, systolic function may not be entirely normal, despite the normal ejection fraction
(EF). There may be a decline in the left ventricular systolic long-axis at earlier stages, followed
by evidence of more greater,subtle defects. On physical training, with decreased augmentation of
function in the long-axis, impairment in systolic twist, decreased global strain, and
electromechanical dys-synchrony will reduce the myocardial systolic reserve [12-14]. The twist
function may alter during oxidative myocardial dysfunction, which may be an early marker of
HF.The physiology of twist mechanics indicate that LV twists in systole store optimal
energy and, during the recoils (untwists) in diastole, cause energy release [13]. It seems that
left ventricular ejection is aided by twist and untwist, which is helpful for the relaxation and
filling of the ventricle. Thus, twist or torsion and rotation are crucial in cardiac contraction

mechanics. Torsion or twist is accompanied by the wringing motion of the heart in its long
axis produced by contraction of the myofibers in the wall of LV [1-3]. The apex and the
base of the heart, during initial isovolumic contraction, both rotate in a counterclockwise
method, if observed from apex to base. However, in the normal heart, the base of the
heart has clockwise rotation during systole and the apex of the heart has counterclockwise
rotation, causing a wringing movement. The cardiologists are not able to understand
the utility of the twist function in clinical practice, which may be due to the problems in
the measurement of cardiac rotation and torsion in the clinic [14]. It seems that 3D-STE may be
an alternative method to assess the twist function, during plane motion. However, it seems that
the measurement of the twist function would enhance our knowledge of physiological mechanics
of the heart, such as the early diagnosis of abnormality in the rotation, indicating sub-endocardial
dysfunction, the second stage of the six stages of HF, that may occur due to behavioral risk
factors such as tobacco and Western diet and obesity [11-14]. These risk factors may be also
helpful in exploring the secrets of the diastole (a Rosetta stone), which could be a new concept in
diastolic function and diastolic HF, via STE, in the light of neuro-humoral dysfunction [14]. It
seems that the physician needs to have a closer look to understand the physio-pathogenesis of
oxidative myocardial function and cardiac dysfunction, with reference to the LV twist and
decline in myocardial strain [11]. There is an unmet need to use rotation and twist, as well as
reversible sub-endocardial and diastole dysfunction in the diastole, via STE, as new markers of
cardiac function, in the presence of oxidative dysfunction of the myocardium [11]. These six
stages of oxidative myocardial dysfunction, proposed by us [5], may be used to begin therapy,
possibly for the primordial prevention of HF, Table 1.
Table 1. Clinical and echocardiographic features of Six Stages of Heart Failure with oxidative
dysfunction.
Stages (HT on
HF)

Manifestations 2D Echocardio
graphic

2D Speckle
Tracking Echo

3D Speckle Tracking
Echo

Stage A Mild to moderate Oxidative
dysfunction, neuro-humoral
dysfunction begins.

Increasing filling
pressure with
abnormal relaxation

Dysfunctional
untwist rate
LA strain reduced
Depression of E/A.

Dysfunctional
Untwist Rate,
LA strain reduced.

Stage B Moderate oxidative
dysfunction, hyper-rotation.
Sub-endocardial
dysfunction.

Dysfunction of
systole

Dysfunctional
untwist rate and
Increased diastolic
pressure. LA strain
decreased

Dysfunctional
untwist rate and
Increased diastolic
pressure. LA strain
decreased

Stage C, PHF Asymptomatic
Physio-Pathological
remodeling+

EF % normal >53% Normal GLS -20- -

23%
≥ −27.0% area
strain

Normal GLS -17 -
21%
Normal AS -31- -36
%

Stage D, PHF
and
HFpEF

Pathological remodeling
disease without symptoms
of HF but elevated
Natriuretic peptide,
dyspnea on exertion

EF% ≥50 %
Systolic LV
dysfunction.

EF% 40- 49 %
Impaired GLS -16-20
%
Impaired GCS,GRS
Impaired early
diastolic
SR, right ventricular
LS,

Impaired GLS-16-
20%
Impaired AS -27-
31%

and global
RV longitudinal SR

Stage E,
HFmrEF

Structural heart disease
with symptoms of HF

EF%40-49%
Grade 1,diastolic
dysfunction

Reduced GLS-12-16%
Reduced GCS, GRS,
Treat with
ACE,ARB.ARNI

GLS ≤ -16%
AS ≤-27 %

Stage F, HFrEF Refractory
class III HF

EF%<40% All above GLS<-12%
Treated with ARNI

GLS <-13%
AS < -27 %
GLS = Global longitudinal strain, GCS = Global circumferential strain, GRS-=Global radial strain, LV =left ventricle , SR = strain
rate, ARNI -=Angiotensin Receptor Neprilysin Inhibitor, mr EF= mild reduction in EF, r-reduction in EF, LA=left atrial
(modified from following references. 13,14)
The Six Stages of Heart Failure.
Stage A and stage B of the Six Stages of HF are: Pre-Heart Failure (PHF). These two early
stages of heart failure are added by our group based on our experience on role of behavioral and
biological risk factors of HF as given in the table [5,11-14]. Stage A is characterized with
dysfunction of the twist whereas in Stage B, sub-endocardial dysfunction is the major criteria of
identification. In view of the absence of clinical manifestations, Stage C may also be considered
PHF [1-3]. It means that patients with PHF are at high risk of developing CHF because they may
have lower myocardial strain indicating dysfunction of the twist and sub-endocardium. Patients
with a family history of HF or having one or more diseases or behavioral risk factors should also
need STE evaluation [4-10]. Experimental studies indicate that prediabetes and diabetes may be
associated with remodeling, which is the earliest indicator of HF and need 2D and 3D STE to
choose suitable intervention [11]. Stage A, B, and C, HF patients should undergo 2D and 3D
STE to assess myocardial strain and twist dysfunction to identify these entities in early stages.
The purpose is to reduce the risk of cardiac hypertrophy and prevent loss of cardiac function.
These patients need an optimal treatment plan, including changes in lifestyle and behavior:
regular moderate exercise, cessation of tobacco consumption, moderation in alcohol intake (<10
drinks per week on 3-4 occasions), low-sodium Indo-Mediterranean diet, adequate night sleep
and yoga therapy [5-10]. Treatment for high blood pressure, blood cholesterol, diabetes and
obesity by medication is also important. In patients with AMI, 3D STE showed that area strain
(AS) ≥ −27.0% was independently linked to increased death risk or HF, indicating which
prognostic parameter can be helpful for the prevention of PHF in patients following AMI [11].
Other stages of HF are Stage C, stage D, Stage E and Stage F.
These stages are similar to criteria laid down by the other experts [4]. The identification of Stage
C, HF should be made as advised above and treated by lifestyle modification in conjunction with
other therapies given in the new guidelines [4].
Stage D, HF, patients in the six stage classification may be graded to have class II HF which
needs preventive lifestyle changes and drug therapy for prevention and progression to NYHA
class III HF. Stage D, HF, patients are already diagnosed to have CHF and have all the clinical
manifestations of HF and lower global longitudinal strain. The standard treatment plan for
patients with Stage D HF with reduced ejection fraction includes all the treatments advised to
stage C patients [5].
Stage E, HF, patients are mostly serious because they are mainly in NYHA class 3 HF. The
treatment of stage E HF includes all the therapies advised to patients with stage D, HF. The

treatment for patients with Stage E, HF may consist of ACE-I or angiotensin II receptor blocker,
and beta -blocker if the patient had a heart attack and EF is 40% or lower [5].
Stage F, HF, patients have marked reduction in ejection fraction and in myocardial strain and
advanced clinical manifestations that do not get better with treatment. This stage of HF may be
associated with marked disability despite treatment. The standard treatment for these HF patients
may be the listed advice of therapy given for Stages D and E, HF patients. Advanced options for
treatment may be evaluated, such as ventricular assist devices, heart surgery, heart transplant,
and continuous infusion of intravenous inotropic agents. Therapies that are in research, like high-
dose coenzyme Q10 (200-400mg/day) and SGLT2 inhibitors, should be tried in all stages of HF
[5].
GLP 1 agonist may be useful in the prevention of Stage, A, B and C HF found in patients with
obesity.Cardiac resynchronization therapy (biventricular pacemaker) and implantable cardiac
defibrillator (lCD) therapy are other possibilities, depending on the status of these patients.
In brief, it is possible to classify HF in to six stages, by considering dysfunction of the twist and
sub-endocardial dysfunction as stage A and B, respectively. Other stages of HF; stage C,D, E
and F are similar to other methods of staging; A,B,C and D, which would need same treatment as
advised in the guidelines. Stage A and B of the Six Stages of HF need particular attention in
treating behavioral risk factors and major risk factors of HF by lifestyle changes and drug
therapy. Cohort studies with STE studies are urgently needed to identify and demonstrate that
this classification proposed by us, has a role in the early diagnosis and prevention of CHF.
Conflict of Interest has not been observed by the editors.
References
1.Stages of Heart Failure, https://my.clevelandclinic.org/health/diseases/17069-heart-failure-
understanding-heart-failure/management-and-treatment , accessed Nov 1,2020
2.Muraru D, NieroA, Rodriguez-Zanella H, Cherata D, Badano L. Three-dimensional speckle-
tracking echocardiography: benefits and limitations of integrating myocardial mechanics with
three dimensional imaging. Cardiovasc Diagn Ther 2018; 8 (1): 101-117.
3.Congestive Heart Failure: Symptoms, Causes, Treatment, Types, Stages.
https://www.webmd.com/heart-disease/guide-heart-failure . Accessed May 2020.
4.Paul A. Heidenreich, Biykem Bozkurt, David Aguilar, Larry A. Allen, Joni J. Byun, Monica
M. Colvin, Anita Deswal, Mark H. Drazner, Shannon M. Dunlay, Linda R. Evers, James C.
Fang, Savitri E. Fedson, Gregg C. Fonarow, Salim S. Hayek, Adrian F. Hernandez, Prateeti
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