See: http://www.aafp.org/afp/2014/0801/p186.html
| Chronic Therapy by Heart Failure Stage | |||
| AHA/ACC Stage (not NYHA class) | Pt characteristics | Treatment | |
| A | High risk for HF. No structural heart disease. Asymptomatic. | HTN, DM, CAD, cardiotoxin exposure. FHx of CMP | Tx focuses on reducing modifiable risk factors, including mgt of HTN, HLD, DM, SVT, Stop smoking, decr. alcohol; incr. exercise. |
| B | Structural heart disease present. Asymptomatic. | Prior MI, decreased EF, LVH or asx valvular disease | Do everything as for stage A, PLUS –ACEI/ARB & BB if MI/CAD or decr. EF. ?ICD. |
| C | Structural heart disease present. Symptomatic: Pt has CHF symptoms (prior or present). | Overt HF | Everything as for stage A, PLUS -ACEI, BB, Diuretics, Sodium restriction. Consider aldosterone antagonist, ICD, CRT. Consider nitrates/hydralazine, digoxin |
| D | Refractory HF requiring specialized interventions | Sx despite max med tx. 4-year mortality >50% |
Everything as for stages A-C, PLUS IV inotropes, VAD, transplant. End of life care. |
*Stage A&B, there is no HF yet.
BB=Beta blockers; ICD = Implantable Cardiac Defibrillator; CRT = Cardiac Resynchronization Therapy.
VAD = Ventricular Assist Device.
CRT is one of the last devices you use before you get to VAD and heart transplant. Watch this video.
From AAFP
“Treatment of stage A heart failure should focus on reducing modifiable risk factors, including management of hypertension and hyperlipidemia.
To prevent symptomatic heart failure, ACE inhibitors and beta blockers should be used in ALL patients with stage B or C heart failure who have a reduced ejection fraction.
Patients with stage C heart failure and fluid retention should be treated with diuretics in addition to ACE inhibitors and beta blockers.“
| NYHA Classification | ||
| Class | Functional State | Symptoms |
| I | No limitation | Asymptomatic during usual daily activities |
| II | Mild limitation | Mild symptoms (dyspnea, fatigue, or chest pain) with ordinary daily activities |
| III | Moderate limitation | Symtoms are noted with minimal activity |
| IV | Severe limitation | Symptoms at rest |
“Heart failure takes on many forms, however, the overall pathology is a failure to pump blood forward at a sufficient rate. Etiologies include ischemic heart disease (coronary atherosclerotic disease) and cardiomyopathy. Cardiac failure can be backward, or “congestive”, versus forward, or “impaired perfusion”. Impaired perfusion symptoms include fatigue, weakness, poor appetite, mental status changes and exercise intolerance. Left-sided congestive failure results in dyspnea, orthopnea, paroxysmal nocturnal dyspnea, pulmonary edema, crackles and pulmonary basilar dullness to percussion. Right-sided failure causes peripheral edema, RUQ discomfort, bloating, ascites, hepatosplenomegaly, hepatojugular reflux, jugular venous distension and increased jugular venous pulsation.”
Check and confirm
AHA/ACC Stages vs NYHA Classes
| ACC/AHA Stage | NYHA Functional Class | ||
|---|---|---|---|
| Stage | Description | Class | Description |
| A | Patients at high risk of developing HF because of the presence of conditions that are strongly associated with the development of HF. Such patients have no identified structural or functional abnormalities of the pericardium, myocardium, or cardiac valves and have never shown signs or symptoms of HF. | No comparable functional class | |
| B | Patients who have developed structural heart disease that is strongly associated with the development of HF but who have never shown signs or symptoms of HF. | I (Mild) |
No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea. |
| C | Patients who have current or prior symptoms of HF associated with underlying structural heart disease. | II (Mild) |
Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea. |
| III (Moderate) |
Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea. | ||
| D | Patients with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy and who require specialized interventions. | IV (Severe) |
Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased. |