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Heart failure

Course of disease

Stages of heart failure (HF) and other classifications1,2

Multiple classification systems have been developed to characterize patients with HF and define those with advanced disease.1

  • New York Heart Association (NYHA) functional class IV defines those with symptoms at rest and with any physical activity.1
  • In 2001, the American College of Cardiology (ACC) and the American Heart Association developed a new construct for defining HF, describing Stage D patients as those who require specialized interventions due to refractory symptoms despite maximal medical therapy.1
  • The Interagency Registry for Mechanically Assisted Circulation (INTERMACS) classification system was developed to risk stratify patients with advanced HF to better define prognosis and urgency of intervention.1

These 3 classification systems may be used in parallel in order to more precisely define where an individual patient lies on the spectrum of this progressive disease1. (Figure 1)

Course_of_disease_Fig_1

 

Figure 1. Classifications of heart failure1

Advanced heart failure is a clinically important designation as it can guide consideration of advanced therapies including transplant and mechanical ventricular assistance. Professional societies including the Heart Failure Society of America (HFSA), the American College of Cardiology (ACC)/ American Heart Association (AHA), the Heart Failure Association (HFA) and the European Society of Cardiology (ESC) have proposed criteria to define this condition. In the 2018 version of the ESC criteria, the diagnosis of advanced heart failure requires several findings which must all be present despite optimized guideline-directed medical therapy. These include severe symptoms (NYHA class 3 or 4), severe cardiac dysfunction with ejection fraction (EF) ≤30%, right ventricular dysfunction, non-operable valvular or congenital heart disease abnormalities, pulmonary congestion or low cardiac output requiring intravenous diuretics or inotropes, and severe reduction in exercise capacity believed to be cardiac in origin2.

Footnotes:

  • ACC, American College of Cardiology; AHA, American Heart Association; EF, ejection fraction; ESC, European Society of Cardiology; HF, heart failure; HFA, Heart Failure Association; HFSA, Heart Failure Society of America; INTERMACS, Interagency Registry for Mechanically Assisted Circulation; NYHA, New York Heart Association.

References:

  1. Truby LK, Rogers JG. 2020;8(7):523-536.

  2. Roger VL. Circ Res. 2021;128(10):1421-1434.

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