Stages of Congestive Heart Failure

AMERICAN COLLEGE OF CARDIOLOGY/AMERICAN HEART ASSOCIATION	NEW YORK HEART ASSOCIATION
Stage A: At risk for heart failure	Class I: No limitation of physical activity
Stage B: Pre-heart failure	Class II: Slight limitation of physical activity.
Stage C: Symptomatic heart failure	Class III: Marked limitation of physical activity
Stage D: Advanced heart failure	Class IV: Symptoms of heart failure at rest

The ACC/AHA system includes people who do not yet have heart failure but may be at risk for the condition. There are four stages in these staging guidelines, which range from stage A to stage D.

Stage A (At Risk for HF) 

In stage A, there are no symptoms of heart failure or evidence of a problem with your heart’s structure and function. Rather, this stage focuses on people who may have certain risk factors for heart failure, such as hypertension (high blood pressure), diabetes, and a family history of heart disease.

Lifestyle changes to reduce the risk of HF are important at this stage. This can include eating a diet full of fruits and vegetables, getting physical activity, maintaining a weight that’s right for you, and limiting tobacco or alcohol use.

Stage B (Pre-HF)

In Stage B, there are no symptoms of HF, but there is evidence of abnormalities in the heart’s structure or blood test results that suggest heart failure. People in this stage may also show certain early signs of HF, like elevated pressure within the heart.

At this point, your provider may suggest medications to control underlying risk factors for heart failure and to prevent symptoms from developing.

Stage C (Symptomatic HF) 

Structural heart disease is present in stage C, which causes symptoms of heart failure. You may develop symptoms like shortness of breath, fatigue, or swelling due to fluid buildup.

Medications and procedures can help prevent heart failure from progressing. Your healthcare provider may also recommend lowering your sodium intake as part of the treatment plan, among other dietary changes if needed.

Stage D (Refractory HF) 

In this stage, symptoms of HF continue even with medications and surgical procedures. These symptoms can significantly affect your daily life or cause an increase in visits to your provider and hospitalizations. People in this stage may also require more intensive management and therapies. Depending on how severe your symptoms are, your provider may also recommend a heart transplant.

If you are in stage C or stage D heart failure, your healthcare provider will also add a New York Heart Association (NYHA) classification to your diagnosis. While there is no time frame on how long you might be in any stage of heart failure, your stage can change based on how well the treatment works. The goal during any stage of HF is to manage symptoms and slow the progression of the condition.

Unlike the ACC/AHA system, the New York Heart Association guidelines only focus on people who are actively experiencing symptoms of heart failure. This is generally for people with stage C or stage D heart failure based on the ACC/AHA system. There are four classes in the NYHA classification system, which range from class I to class IV.

Class I

Class I includes people who have HF but no limitation on physical activity. In this class, you can still complete daily activities like walking or climbing stairs without experiencing heart failure symptoms. But more rigorous activity can cause symptoms.

At this stage, your heart’s ability to pump blood is still close to normal, and you don’t need to make major changes to your daily routine. However, treatment will focus on improving overall heart health to prevent you from progressing to class II and beyond.

Class II

In class II, you may notice a slight limitation of physical activity. You’ll likely feel comfortable at rest, but activities like brisk walking or climbing the stairs may cause heart failure symptoms like shortness of breath, fatigue, or mild chest pain.

During this stage, your heart may start to lose its ability to pump blood properly. Your healthcare provider will thereby recommend treatments to manage symptoms and improve quality of life.

Class III

Class III represents a noticeable limitation of physical activity. While you likely feel comfortable at rest, minimal physical exertion like walking short distances or completing everyday household chores can cause symptoms to flare.

In this stage, treatment goals focus on reducing symptoms, preventing hospitalizations, and improving daily functioning.

Class IV

Class IV occurs when severe symptoms persist even at rest. Any physical activity, no matter how minimal, can worsen your symptoms. At this stage, your heart function is considered to be significantly impaired.

Your treatment plan will likely focus on alleviating symptoms and improving comfort and quality of life. People in Class IV may also require more intensive medical therapies, like heart transplants or mechanical support devices.

Medications and surgical procedures are the most common treatments to help slow the progression of heart failure. An early diagnosis is important can improve your quality and longevity of life. The sooner you find out about your condition, the earlier you’re able to get the treatment you need to prevent the condition from worsening.

Following your treatment plan and implementing lifestyle strategies like eating nutritiously, getting exercise, and managing stress can help slow down the progression of your condition.

Living with HF involves navigating different challenges at each stage. In the early stages (stages A and B), you may not experience symptoms, but it’s important to implement lifestyle changes that help lower the risk of heart failure. As the condition progresses to stages C and D, symptoms can affect your daily life, and complications can start to occur.

However, prioritizing your heart health and emotional well-being remains important, and you can live well with your condition. Consider these strategies to improve your health and quality of life:

• Eat heart-healthy foods, such as fruits, vegetables, lean proteins, and whole grains
• Move your body through exercises you enjoy, such as walking, swimming, or dancing
• Rely on your loved ones for social and emotional support as you process your diagnosis
• Make time for activities and hobbies that reduce stress and bring joy
• Reach out to a mental health care provider if your diagnosis is taking a toll on your emotions
• Ask your healthcare provider questions about your life expectancy and how to move forward with life planning

Heart failure occurs when the structure or function of the heart becomes impaired, making it difficult for it to pump blood to other organs. Healthcare providers use two complementary staging systems to determine the stage of heart failure: the ACC/AHA system (stages A through D) and the NYHA system (classes I through IV).

Your symptoms and their severity will depend on your stage, but treatments like medications, lifestyle changes, and surgery can improve your quality of life.