The Classes and Stages of Heart Failure

Helpful Highlights

• Heart failure is categorized into four classes, 1-4.

• Heart failure is also categorized into four stages, A-C.

• The class and stage say a lot about the status of your loved one's heart failure and can guide what you can do to help.

What is heart failure?

A chronic (not curable), progressive (gets worse) condition in which the heart muscle is not able to pump enough blood to meet the body's demands for blood and oxygen. Heart failure occurs when it cannot pump (systolic) or fill (diastolic) adequately. This inadequacy often leads to an accumulation in other parts of the body, namely the lungs and lower extremities (feet, ankles, lower legs).

What is the prognosis for people with heart failure?

A prognosis is the likely course of a disease or ailment, including short-term and long-term outlooks and expectations. The prognosis for heart failure varies widely and depends on whether the underlying cause can be treated. The prognosis accounts for several factors:

• Heart failure cause and severity

• How quickly care is received 

• Overall health and response to treatment

• Commitment to heart-healthy living

How can I help my loved one?

• Be vigilant and keep providers informed, especially if symptoms worsen

• Talk often, openly, and frankly with your loved one about their experiences

• Stay positive and encourage your loved one to stay on their treatment plan

Classes of heart failure

Classes are defined by the New York Heart Association (NYHA).

Class 1. A person has no adverse symptoms and no limitation of physical activity.

Class 2. A person has mild symptoms and a slight limitation of physical activity but is comfortable doing ordinary activities.

Class 3. A person has significant symptoms and marked limitation of physical activity and is comfortable only at rest.

Class 4. A person has severe symptoms and cannot engage in physical activity without discomfort, and experiences symptoms even at rest.

Stages of heart failure

Stages of heart failure, which complement the classes, are defined by the American College of Cardiology (ACC) and the American Heart Association (AHA). The stages also come with recommendations for respective treatments.

Stage A. Stage A is considered pre-heart failure. A person is at high risk of developing heart failure but they have no structural heart disease or symptoms of heart failure.

• Treatment recommendations: Quit smoking, exercise regularly, treat high blood pressure (hypertension), treat high cholesterol, discontinue alcohol or illegal drug use, and keep taking medications as prescribed for coronary artery disease, diabetes, or other cardiovascular conditions.

Stage B. Stage B is also considered pre-heart failure. A person has structural heart disease but still no symptoms of heart failure.

• Treatment recommendations: Take an ACE-inhibitor (angiotensin-converting enzyme inhibitor) or ARB (angiotensin receptor blocker), beta-blockers should be prescribed in the event of a heart attack, and surgical options should be discussed for coronary artery or heart valve disease.

Stage C. Stage C is diagnosed heart failure. A person has structural heart disease and prior or current symptoms of heart failure.

• Treatment recommendations: African Americans may be prescribed a hydralazine/nitrate combination if symptoms persist, diuretics ("water pills") and digoxin may be prescribed if symptoms persist, and aldosterone inhibitor may be prescribed with other therapies when symptoms remain severe, sodium (salt) intake restrictions, weight monitoring, fluid restrictions (only as prescribed), pacemaker or ICD (implantable cardioverter defibrillator) may be recommended.

Stage D. Stage D is refractory (doesn't respond to treatment) heart failure requiring specialized interventions. A person has advanced structural heart disease and persistent, significant to severe symptoms of heart failure. Stage D is commonly referred to as "end stage" heart failure.

• Treatment recommendations: Evaluation for heart transplant, VAD (ventricular assist device), surgical options, research therapies, continuous infusion of inotropic drugs, palliative care, and hospice (end-of-life) care.