Congestive heart failure classification

Congestive Heart Failure Microchapters
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Overview
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Pathophysiology Systolic Dysfunction Diastolic Dysfunction HFpEF HFrEF
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Differentiating Congestive heart failure from other Diseases
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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 Positive Inotropics Anticoagulants Angiotensin Receptor-Neprilysin Inhibitor Antiarrhythmic Drugs Nutritional Supplements Hormonal Therapies Drugs to Avoid Drug Interactions Treatment of underlying causes 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]

Overview

There are several classification schemes used to characterize the types of heart failure (systolic or diastolic), to assess the severity of heart failure (the NY Heart Association Class) and to assess the stage congestive heart failure (AHA Class A,B,C,D).

Systolic versus Diastolic Heart Failure

Patients may be broadly classified as having heart failure with depressed contractility or depressed relaxation

Systolic Dysfunction

The left ventricular ejection fraction is reduced in systolic dysfunction and there is depressed contractility of the heart.

Disastolic 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 sided versus right sided).

Left Heart Failure

• There is impaired left ventricular function with reduced flow into the aorta.

Right Heart Failure

• There is impaired right ventricular function with 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 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. 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.

Assessing 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 of 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.

Guidelines Resources

• The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

• 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