Congestive heart failure classification

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Overview

Historical Perspective

Classification

Pathophysiology

Systolic Dysfunction
Diastolic Dysfunction
HFpEF
HFrEF

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Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors

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Natural History, Complications and Prognosis

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Medical Therapy:

Summary

Acute Pharmacotherapy

Chronic Pharmacotherapy in HFpEF

Chronic Pharmacotherapy in HFrEF

Diuretics
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
Hydralazine
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Angiotensin Receptor-Neprilysin Inhibitor
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Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief:  Mitra Chitsazan, M.D.[2], Sara Zand, M.D.[3] Jair Basantes de la Calle, M.D.

## Overview

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LVEF has an important role in the classification of patients with HF because of differing prognosis and response to treatments. In the guideline of 2022 AHA, HFrEF is defined as LVEF ≤40% . HF with preserved EF (HFpEF) including approximately 50% of the population with HF with increased prevalence. HFpEF is defined as LVEF ≥50%. Heaet failure improved EF is considered when follow-up LVEF reaches more than 40%.

## Classification

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Several classification systems are used to characterize heart failure according to the: [1] [2]

* The pathophysiology of heart failure:
* Systolic vs diastolic heart failure
* Left-sided, right-sided or biventricular heart failure
* Low output vs high output heart failure
* The underlying physiology based on left ventricular ejection fraction:
* Heart failure with reduced ejection fraction (HFrEF), heart failure with mid-range ejection fraction (HFmrEF), heart failure with preserved ejection fraction (HFpEF)
* The chronicity of heart failure:
* acute or chronic
* The severity of symptoms of heart failure:
* New York Heart Association Class (NYHA class)
* Killip class (severity of the symptoms in the acute setting after myocardial infarction)
* The stage (progression of the disease) of congestive heart failure:
* The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) classification: A, B, C, D.

### 1\. Systolic versus Diastolic Heart Failure

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* Systolic Dysfunction: The left ventricular ejection fraction is reduced in systolic dysfunction and there is depressed contractility of the heart.
* Diastolic Dysfunction: The left ventricular ejection fraction is preserved in diastolic dysfunction and there is an abnormality in myocardial relaxation or excessive myocardial stiffness. Systolic and diastolic dysfunction commonly occur in conjunction with each other.

### 2\. Left-, Right- and Biventricular Failure

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Another common method of classifying heart failure is based upon the ventricle involved.

* Left-ventricular Heart Failure: There is impaired left ventricular function with the reduced flow into the aorta.
* Right-ventricular Heart Failure: There is impaired right ventricular function with the reduced flow into the pulmonary artery and lungs.
* Biventricular Failure: The most common cause of right heart failure is left heart failure, and mixed presentations are common, especially when the cardiac septum is involved.

### 3\. High output versus Low output Heart Failure

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* Low Output Failure: The cardiac output is reduced, and the systemic vascular resistance (SVR) is high. In low output failure, there is an inadequate supply of blood flow to meet normal metabolic demands.
* High Output Failure: The cardiac output is increased, and the systemic vascular resistance (SVR) is low. Rather than an inadequate supply of blood flow to meet normal metabolic demands as occurs in low output failure, in high output failure there is an excess requirement for oxygen and nutrients and the demand outstrips what the heart can provide.[3] Causes of high output heart failure include severe anemia, Gram negative septicaemia, beriberi (vitamin B1/thiamine deficiency), thyrotoxicosis, Paget's disease, arteriovenous fistulae, or arteriovenous malformations.

### 4\. Classification of Heart Failure Based on the Ejection Fraction (EF)

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* HFrEF is defined as LVEF <_40% or significant reduction in LV systolic function.
* HFmrEF is defined when LVEF is between 41% and 49% or there is mildly reduced LV systolic function.
* HF p EF is defined as LVEF >_50%, with symptoms and signs of heart failure , with evidence of structural and/or functional cardiac abnormalities and/or high level of natriuretic peptides (NPs).

Abbreviations: HF: Heart failure; HFmrEF: Heart failure with mildly reduced ejection fraction; HFpEF: Heart failure with preserved ejection fraction ; HFrEF: Heart failure with reduced ejection fraction; LV: Left ventricle; LVEF: Left ventricular ejection fraction;

HFrEF | HFmrEF | HFpEF

|
|

Symptoms± Signs, LVEF ≤ 40%  | Symptoms± Signs, LVEF ≥ 41%-49%  | Symptoms± Signs, LVEF≥ 50%, cardiac structure and function abnormalities,

LV diastolic dysfunction, high LV filling pressures, high natriuretic peptides

The above table adopted from 2021 ESC Guideline

[4]

Classification of heart failure by LVEF

Type of heart failure according to LVEF | Criteria
HFrEF (heart failure with reduced EF)  | LVEF ≤ 40%
HFimpEF ( heart failure with improved EF)  |

Previous LVEF ≤ 40% and a follow-up measurement of LVEF>40%

HFmrEF (heart failure with mildly reduced EF)  |

* LVEF 41%-49%
* Evidence of increased LV filling pressure (elevated natriuretic peptide, non-invasive and invasive hemodynamic measurement)

HFpEF (heart failure with preserved EF)  |

* LVEF≥ 50%
* Evidence of increased LV filling pressure (elevated natriuretic peptide, non-invasive and invasive hemodynamic measurement)

The above table adopted from 2022 AHA Guideline

[5]

### 5\. Chronicity of Heart Failure

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* Acute or Decompensated: Acute or decompensated heart failure is a term used to describe exacerbated or decompensated heart failure, and refers to an episode in which a patient sustains a change in heart failure signs and symptoms that necessitates urgent therapy or hospitalization.[6]
* Chronic: There is stable symptomatology in chronic heart failure.

### 6\. The Severity of Heart Failure

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The NYHA functional classification is used to describe the severity of symptoms and exercise intolerance in patients with congestive heart failure.

The New York Heart Association Criteria (NYHA)

NYHA Class | Definition
NYHA I | No symptoms with ordinary activity
NYHA II |

Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or angina.

NYHA III |

Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.

NYHA IV | Unable to carry out any physical activity without discomfort. Symptoms are present at rest.

### 7\. The Stages of heart failure

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The ACC/AHA classification system was introduced to emphasize the natural history of the heart failure syndrome and to identify opportunities to intervene earlier and prevent disease progression.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Stages of Heart Failure

Stages | Definition | Example | Corresponding NYHA class
A  |

* Patients at high risk for developing HF but without structural heart disease or symptoms of heart failure or biomarkers within normal ranges.

* Hypertension
* Diabetes mellitus
* Coronary artery disease
* History of Exposure to cardiac toxins:
* History of cardiotoxic drug therapy.
* History of alcohol abuse.
* Familial history of cardiomyopathy

| None
B  | Patients without current or previous sings/ symptoms of HF but evidence of the following:  |

* Structural heart diseases.
* Increased filling pressures in the heart.
* Increased levels of Natriuretic peptide.
* Persistently elevated cardiac diagnosis with no diagnosis.

| NYHA class I
C  | Patient with past or current symptoms/ signs of HF  | The trajectory of Stage C HF:

* New onset/ De Novo HF
* Resolution of symptoms
* Persistent HF
* Worsening HF

| NYHA classes I, II, III, and IV
D  | Profound HF symptoms.  | Patients have symptoms that interfere with daily life activities. They may also have recurrent hospitalizations despite attempts to optimize guideline-directed medical therapy.  | NYHA class IV

[5]

## References

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1. ↑ Aurigemma GP (2006). "heart failure--a common and lethal condition by any name". N Engl J Med. 355 (3): 308–10. doi:10.1056/NEJMe068128. PMID 16855273.
2. ↑ Yancy CW, Jessup M, Bozkurt B, Masoudi FA, Butler J, McBride PE; et al. (2013). "2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. doi:10.1016/j.jacc.2013.05.019. PMID 23747642.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
3. ↑ Template:DorlandsDict
4. ↑ McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland J, Coats A, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam C, Lyon AR, McMurray J, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano G, Ruschitzka F, Kathrine Skibelund A (September 2021). "2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure". Eur Heart J. 42 (36): 3599–3726. doi:10.1093/eurheartj/ehab368. PMID 34447992 Check `|pmid=` value (help). Vancouver style error: initials (help)
5. ↑ 5.0 5.1 Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM; et al. (2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e876–e894. doi:10.1161/CIR.0000000000001062. PMID 35363500 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
6. ↑ Jessup. M, et al. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation. 2009 Apr 14;119(14):1977-2016. PMID 19324967