Congestive heart failure classification: Difference between revisions
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*The pathophysiology of heart failure: | *The pathophysiology of heart failure: | ||
**Systolic vs diastolic heart failure | **Systolic vs diastolic heart failure | ||
**Left-sided | **Left-sided, right-sided OR biventricular heart failure | ||
**Low output vs high output heart failure | **Low output vs high output heart failure | ||
*The underlying physiology based on [[left ventricular ejection fraction]] | *The underlying physiology based on [[left ventricular ejection fraction]] | ||
| Line 25: | Line 25: | ||
**Killip class (severity of the symptoms in the acute setting after myocardial infarction) | **Killip class (severity of the symptoms in the acute setting after myocardial infarction) | ||
*The stage (progression of the disease) of congestive heart failure | *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. | **The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) classification: A, B, C, D. | ||
===Systolic versus Diastolic Heart Failure=== | ===Systolic versus Diastolic Heart Failure=== | ||
====Systolic Dysfunction==== | ====Systolic Dysfunction==== | ||
The [[left ventricular ejection fraction]] is reduced in [[systolic dysfunction]] and there is depressed contractility of the heart. | The [[left ventricular ejection fraction]] is reduced in [[systolic dysfunction]] and there is depressed contractility of the heart. | ||
====Diastolic Dysfunciton==== | ====Diastolic Dysfunciton==== | ||
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. | 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. | ||
===Left, Right and Biventricular Failure=== | ===Left, Right and Biventricular Failure=== | ||
Another common method of classifying heart failure is based upon the ventricle involved | Another common method of classifying heart failure is based upon the ventricle involved. | ||
====Left Heart Failure==== | ====Left-ventricular Heart Failure==== | ||
*There is impaired left ventricular function with reduced flow into the aorta. | *There is impaired left ventricular function with the reduced flow into the aorta. | ||
====Right Heart Failure==== | ====Right-ventricular Heart Failure==== | ||
*There is impaired right ventricular function with reduced flow into the pulmonary artery and lungs. | *There is impaired right ventricular function with the reduced flow into the pulmonary artery and lungs. | ||
====Biventricular Failure==== | ====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. | *The most common cause of right heart failure is left heart failure, and mixed presentations are common, especially when the cardiac septum is involved. | ||
===High | |||
===High output versus Low output Heart Failure=== | |||
====Low Output Failure==== | ====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. | *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==== | ====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.<ref>{{DorlandsDict|nine/000953450|high-output heart failure}}</ref> Causes of high output heart failure include severe [[anemia]], Gram negative [[septicaemia]], [[beriberi]] (vitamin B<sub>1</sub>/thiamine deficiency), [[thyrotoxicosis]], [[Paget's disease of bone|Paget's disease]], [[arteriovenous fistula]]e, or [[arteriovenous malformation]]s. | *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.<ref>{{DorlandsDict|nine/000953450|high-output heart failure}}</ref> Causes of high output heart failure include severe [[anemia]], Gram negative [[septicaemia]], [[beriberi]] (vitamin B<sub>1</sub>/thiamine deficiency), [[thyrotoxicosis]], [[Paget's disease of bone|Paget's disease]], [[arteriovenous fistula]]e, or [[arteriovenous malformation]]s. | ||
===Chronicity of Heart Failure=== | ===Chronicity of Heart Failure=== | ||
====Acute or Decompensated==== | ====Acute or Decompensated==== | ||
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There is stable symptomatology in chronic heart failure. | There is stable symptomatology in chronic heart failure. | ||
=== | ===The Severity of Heart Failure=== | ||
====The New York Heart Association Criteria (NYHA)==== | |||
*'''[[New york heart association functional classification#New York Heart Association Functional Classification (NYHA)|NYHA I]]:''' No symptoms with ordinary activity. | *'''[[New york heart association functional classification#New York Heart Association Functional Classification (NYHA)|NYHA I]]:''' No symptoms with ordinary activity. | ||
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*'''[[New york heart association functional classification#New York Heart Association Functional Classification (NYHA)|NYHA III]]:''' Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in [[fatigue]], [[palpitation]], [[dyspnea]], or [[chest pain|anginal pain]]. | *'''[[New york heart association functional classification#New York Heart Association Functional Classification (NYHA)|NYHA III]]:''' Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in [[fatigue]], [[palpitation]], [[dyspnea]], or [[chest pain|anginal pain]]. | ||
*'''[[New | *'''[[New York heart association functional classification#New York Heart Association Functional Classification (NYHA)|NYHA IV]]:''' Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency present at rest. | ||
===ACC/AHA Classification of Chronic Heart Failure Based on the Structural and Symptomatic Stages of the Syndrome=== | ===ACC/AHA Classification of Chronic Heart Failure Based on the Structural and Symptomatic Stages of the Syndrome=== | ||
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. | |||
==== Stage A ==== | ==== Stage A ==== | ||
Patients “at Risk” | Patients “at Risk” | ||
| Line 93: | Line 91: | ||
====Stage D==== | ====Stage D==== | ||
Despite | Despite maximal medical therapy, symptoms of heart failure at rest and advanced structural heart disease. | ||
* Being considered for advance options including [[LVAD]] and [[heart transplantation]]. | * Being considered for advance options including [[LVAD]] and [[heart transplantation]]. | ||
* Requiring continuous [[inotropic]] or mechanical support. | * Requiring continuous [[inotropic]] or mechanical support. | ||
* Receiving or being considered for palliative care/end of life care. | * Receiving or being considered for palliative care/end-of-life care. | ||
=== Classification of Heart Failure Based on the Ejection Fraction (EF)=== | === Classification of Heart Failure Based on the Ejection Fraction (EF)=== | ||
* The 2013 ACC/AHA guidelines indicated that the EF is the most accurate way to classify heart failure rather than systolic vs diastolic. That is due to the variation in the definition of systolic dysfunction with some defines it as an EF < 35%, < 40% and <= 40%. | * The 2013 ACC/AHA guidelines indicated that the EF is the most accurate way to classify heart failure rather than systolic vs diastolic. That is due to the variation in the definition of systolic dysfunction with some defines it as an EF < 35%, < 40% and <= 40%. | ||
* For 2013 guideline, HFrEF is defined as the clinical diagnosis of heart failure, with an EF less than or equal to 40%. | * For the 2013 guideline, HFrEF is defined as the clinical diagnosis of heart failure, with an EF less than or equal to 40%. | ||
* HFpEF is defined as symptoms of heart failure and EF= 40-50%. | * HFpEF is defined as symptoms of heart failure and EF= 40-50%. | ||
Revision as of 11:19, 13 August 2021
 |
Resident Survival Guide |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]
Overview
There are several classification schemes used to characterize the pathophysiology of heart failure as either systolic vs diastolic; left vs right; or low output vs high output.
Classification
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.
Systolic versus Diastolic Heart Failure
Systolic Dysfunction
The left ventricular ejection fraction is reduced in systolic dysfunction and there is depressed contractility of the heart.
Diastolic Dysfunciton
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.
Left, Right and Biventricular Failure
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.
High output versus Low output Heart Failure
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.
Chronicity of Heart Failure
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.[4]
Chronic
There is stable symptomatology in chronic heart failure.
The Severity of Heart Failure
The New York Heart Association Criteria (NYHA)
- 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 of cardiac insufficiency present at rest.
ACC/AHA Classification of Chronic Heart Failure Based on the Structural and Symptomatic Stages of the Syndrome
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.
Stage A
Patients “at Risk”
- Hypertension
- Diabetes mellitus
- Coronary artery disease
- Exposure history to cardiac toxins:
- History of cardiotoxic drug therapy.
- History of alcohol abuse.
- Familial history of cardiomyopathy
Stage B
Patients with structural heart disease, but no history of signs or symptoms of heart failure.
- Left ventricular hypertrophy (LVH)
- Myocardial fibrosis
- Left ventricular dilatation or dysfunction
- Asymptomatic valvular heart disease
- Previous myocardial infarction
Stage C
Underlying structural heart disease and symptoms of heart failure.
- Dyspnea or fatigue due to left ventricular systolic dysfunction.
- Asymptomatic patients receiving treatment for prior symptoms of heart failure.
Stage D
Despite maximal medical therapy, symptoms of heart failure at rest and advanced structural heart disease.
- Being considered for advance options including LVAD and heart transplantation.
- Requiring continuous inotropic or mechanical support.
- Receiving or being considered for palliative care/end-of-life care.
Classification of Heart Failure Based on the Ejection Fraction (EF)
- The 2013 ACC/AHA guidelines indicated that the EF is the most accurate way to classify heart failure rather than systolic vs diastolic. That is due to the variation in the definition of systolic dysfunction with some defines it as an EF < 35%, < 40% and <= 40%.
- For the 2013 guideline, HFrEF is defined as the clinical diagnosis of heart failure, with an EF less than or equal to 40%.
- HFpEF is defined as symptoms of heart failure and EF= 40-50%.
Guidelines Resources
- The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult [5]
- 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation [6]
References
- ↑ 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.
- ↑ 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.
- ↑ Template:DorlandsDict
- ↑ 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
- ↑ Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al. (2005) ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 112 (12):e154-235. DOI:10.1161/CIRCULATIONAHA.105.167586 PMID: 16160202
- ↑ Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967