Heart Failure Classifications

Heart failure (HF) is a condition that affects millions of people worldwide. Understanding its stages and classifications can help you get the right diagnosis and treatment. Heart failure can be classified by stage or by class.¹

The 4 stages of heart failure

The American College of Cardiology (ACC) has developed a system to classify HF into 4 stages: A, B, C, and D. These stages help doctors determine the severity of your condition. It also allows them to choose the best course of treatment.^1-3

As HF worsens, the condition advances to the next stage. There is no moving backward through the stages. With treatment, however, you may be able to slow your progression through the stages.¹

Stage A: At high risk of heart failure

In stage A, people experience no symptoms and show no structural signs of HF, but they are at high risk of developing it. Conditions that put them at higher risk than other people include:^1-4

• High blood pressure (hypertension)
• Coronary artery disease
• Diabetes
• Obesity
• Family history of heart disease

Stage B: Pre-heart failure

In stage B, there is evidence of an enlarged, weakened, or otherwise structurally changed heart. But there are no noticeable symptoms yet. A person in this stage may have:^1-4

• Previous heart attack
• Heart valve problems
• Enlarged heart muscle

Stage C: Symptomatic heart failure

In stage C, people have structural heart disease and have symptoms of HF. These symptoms include:^1,4

• Shortness of breath
• Fatigue
• Swelling in the legs, ankles, or feet (edema)

This stage is where most people are diagnosed. Treatment focuses on managing symptoms and preventing further damage to the heart.^1,4

Stage D: Advanced heart failure

Stage D is the most severe stage. In this stage, people have advanced symptoms that can greatly impact daily life and generally do not respond to conventional treatment. These symptoms may include:^1-4

• Severe shortness of breath, even at rest
• Persistent coughing and/or wheezing
• Fluid buildup in the abdomen (ascites)

The 4 classes of heart failure

The New York Heart Association (NYHA) Functional Classification categorizes HF based on the severity of symptoms and how they affect daily activities. If you have reached stage C or D heart failure, doctors will assess your symptoms and determine which class of HF you fall in. There are 4 classes.^1,3,4

Class 1: No limitation of physical activity

People in class 1 have heart disease but do not have any symptoms during ordinary physical activity. They can perform daily tasks without feeling fatigued or short of breath.^1,3,4

Class 2: Slight limitation of physical activity

In class 2, people have some limitations on physical activity. Ordinary activities might cause some fatigue, shortness of breath, or heart palpitations. But they are comfortable when they are at rest.^1,3,4

Class 3: Marked limitation of physical activity

In class 3, people are limited in what physical activity they can do. Even minor activities like walking across the room cause symptoms like fatigue and shortness of breath. However, they are still comfortable at rest.^1,3,4

Class 4: Symptoms of heart failure at rest

Class 4 is the most severe classification. People experience symptoms of HF even while at rest, and any physical activity increases their discomfort. At this stage, medical attention is needed. Intensive treatment, such as surgery, mechanical heart support, or a heart transplant, may be necessary.^1,3,4

Measuring ejection fraction

Another way to diagnose stages of HF is to measure the heart’s ejection fraction. The ejection fraction describes the pumping ability of the heart. It measures the percentage of blood pumped out of the heart each time it contracts.⁴

With every beat, your heart pumps blood throughout the body. When your heart’s pumping ability is impaired, your ejection fraction measurement decreases. A normal ejection fraction is between 50 and 70 percent.⁴

Having HF does not necessarily mean that you will have a reduced ejection fraction. Different medicines may be used based on whether you have reduced or normal ejection fraction.⁴

Managing heart failure

Understanding the stages and classes of heart failure is crucial for effective management. Here are some general tips for managing heart failure:^1,4

• Medicines – Take medicines as prescribed to manage symptoms and prevent HF from getting worse.
• Lifestyle changes – Eat a healthy, low-salt diet, exercise regularly, and avoid smoking and alcohol.
• Regular checkups – See your doctor regularly to monitor your condition and adjust treatments as necessary.
• Symptom monitoring – Keep track and tell your doctor if you have any new or changing symptoms.

Heart failure is a serious condition. But with proper management and support, people can lead fulfilling lives. If you or a loved one is dealing with heart failure, contact your doctor for a full evaluation.^1,4