Classes and Stages of Heart Failure

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It is important to remember that many people with heart failure lead full, enjoyable lives. Also, not all heart failure is the same.

Heart failure can progress, so researchers have identified four stages of the disease — A, B, C and D. Health care professionals also classify heart failure when it has progressed to stages C and D. This classification measures a patient’s overall heart function and severity of symptoms.

Stages of Heart Failure

In collaboration with the American College of Cardiology, the AHA has identified four stages of heart failure. They are described in the table below.

Stage A:
At risk for heart failure

People who are at risk for heart failure but do not yet have symptoms or structural or functional heart disease

Risk factors for people in this stage include hypertension, coronary vascular disease, diabetes, obesity, exposure to cardiotoxic agents, genetic variants for cardiomyopathy and family history of cardiomyopathy

Stage B:
Pre-heart failure
People without current or previous symptoms of heart failure but with either structural heart disease, increased filling pressures in the heart or other risk factors
Stage C:
Symptomatic heart failure
People with current or previous symptoms of heart failure
Stage D:
Advanced heart failure
People with heart failure symptoms that interfere with daily life functions or lead to repeated hospitalizations

Classes of Heart Failure

By classifying patients in stage C and stage D heart failure, health care professionals better understand how to treat people in these more advanced stages. Health care professionals typically classify patients' heart failure according to the severity of their symptoms.

The most commonly used classification system, the New York Heart Association (NYHA) Functional Classification1, places patients in one of four categories based on limitations of physical activity.

If you are diagnosed with stage C or stage D heart failure, your health care professional will give you an NYHA Functional Classification as a baseline. Then, as you undergo treatment, your health care professional will assign another classification of your condition, allowing your care team to measure how well treatment is working.

The table below describes the different classes in the NYHA Functional Classification.

Class Patient Symptoms
I No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation or shortness of breath.
II Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, shortness of breath or chest pain.
III Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, shortness of breath or chest pain.
IV Symptoms of heart failure at rest. Any physical activity causes further discomfort.

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1 Adapted from Dolgin M, Association NYH, Fox AC, Gorlin R, Levin RI, New York Heart Association. Criteria Committee. Nomenclature and criteria for diagnosis of diseases of the heart and great vessels. 9th ed. Boston, MA: Lippincott Williams and Wilkins; March 1, 1994.
Original source: Criteria Committee, New York Heart Association, Inc. Diseases of the Heart and Blood Vessels. Nomenclature and Criteria for diagnosis, 6th edition Boston, Little, Brown and Co. 1964, p 114.
©1994 American Heart Association, Inc.

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