Congestive heart failure classification

Resident Survival Guide

Congestive Heart Failure Microchapters
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Overview
Historical Perspective
Classification
Pathophysiology Systolic Dysfunction Diastolic Dysfunction HFpEF HFrEF
Causes
Differentiating Congestive heart failure from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Clinical Assessment
History and Symptoms
Physical Examination
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Electrocardiogram
Chest X Ray
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Exercise Stress Test
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Invasive Hemodynamic Monitoring
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];Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.[2],

Overview

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

Several classification systems are used to characterize heart failure according to the:

• 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

• 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

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

• 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.

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

• 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

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. 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.
• Chronic: There is stable symptomatology in chronic heart failure.

6. The Severity of Heart Failure

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

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.

ACC/AHA Classification of Chronic Heart Failure Based on the Structural and Symptomatic Stages of the Syndrom
Stages	Definition	Example	Corresponding NYHA class
A	Patient at high risk for developing HF but without structural heart disease or symptoms of heart failure	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	Patient with structural heart disease who has never developed signs/symptoms of HF	Left ventricular hypertrophy (LVH) Myocardial fibrosis Left ventricular dilatation or dysfunction Asymptomatic valvular heart disease Previous myocardial infarction	NYHA class I
C	Patient with past or current symptoms of HF associated with structural heart disease	Patients with known structural heart disease and symptoms of dyspnea, fatigue, reduced exercise tolerance	NYHA classes I, II, III, and IV
D	Patient with refractory (end-stage) disease who requires specialized treatment strategies such as mechanical circulatory support, continuous inotropic infusions, cardiac transplantation, or hospice care	Patients who have marked symptoms at rest despite maximal medical therapy	NYHA class IV