The stages of heart failure

The American Heart Association and the American College of Cardiology defined the specific stages of heart failure in 2001 to show patients where they stand and the range of therapies they can expect at that point. For their own purposes, physicians also refer to New York Heart Association clinical categories, which rank patients from Class I to IV according to functional limitations and the severity of symptoms.

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Below are the AHA/ACC stages. The following therapies may or may not apply to you, depending on the cause of your heart failure and your specific medical condition. This guide is meant to assist you in discussing treatment options with your physician.

Stage A: No diagnosis or symptoms of heart failure, but the risk is high because of one or more of the following factors: hypertension; diabetes; known coronary artery disease and history of a heart attack; history of cardiotoxic drugs (therapeutic or recreational) or alcohol abuse; history of rheumatic fever; and family history of cardiomyopathy.

Usual therapies: Stop smoking and exercise. Treat hypertension and high blood levels of cholesterol and triglycerides. Stop use of alcohol and illicit drugs. Your doctor may prescribe an angiotensin-converting enzyme (ACE) inhibitor if you have had a previous heart attack, hypertension, or diabetes and a beta blocker if you have had a previous heart attack.

Stage B: Heart failure diagnosed by an ejection fraction (a test measuring the amount of blood pumped out of the main pumping chamber with each heartbeat) below 40 percent (compared with a normal 55 percent or more) but no past or current symptoms.

Usual therapies: All therapies in Stage A plus: Get a surgical consultation for coronary artery revascularization and valve repair or replacement (as appropriate). Your doctor should prescribe an ACE inhibitor and beta blocker (unless contraindicated).

Stage C: Heart failure diagnosed, with past or current symptoms, including shortness of breath, fatigue, and reduced exercise tolerance.

Usual therapies: All therapies in Stage A plus: All patients should take an ACE inhibitor and beta blocker. Your doctor may also prescribe a diuretic and digoxin, if appropriate. All patients should restrict their intake of salt, monitor their weight, and restrict fluid intake (as appropriate). Discontinue drugs that make the condition worse. Your doctor may prescribe spironolactone when symptoms remain severe with other therapies.

Stage D: Advanced symptoms of heart failure after receiving optimal medical care.

Usual therapies: All therapies in Stages A, B, and C plus: evaluation for other treatment options, such as a heart transplant, ventricular-assist device, other surgeries, continuous IV infusion of inotropic drugs, and research therapies.