The 4 Stages of Heart Failure

Brian Jaski

• Publisher: Cardiotext Publishing
• Year: 2015
• ISBN:
  9781935395317
• Edition: 1
• Topic: Medicine
• Subtopic: Cardiology

This book applies practical clinical concepts to the latest four-stage model of heart failure from preclinical risk and early asymptomatic disease to classic symptomatic heart failure and finally advanced heart failure. This framework emphasizes a tailored approach to ongoing heart failure assessment to guide therapy and improve outcomes.Features: • Illustrated with over 250 full-color figures• Specific recommendations backed by clinical trial data• Practical algorithms for diagnosis and therapyTopics include: • Prevention of heart failure• Identification and treatment of structural heart disease prior to heart failure• How to combine lifestyle changes, medications, and devices to improve outcomes• Reversing decompensated heart failure• Key indicators of advanced heart failure and appropriate treatment options• Emerging new therapies

CHAPTER 1

Heart Failure Diagnosis and Epidemiology

FAST FACTS

• Heart failure diagnosis is usually based on Framingham criteria: either two major, or one major and two minor criteria. Less severe heart failure can manifest without fulfilling these criteria.

• The ACCF/AHA 4 Stages (A, B, C, D) and the New York Heart Association functional classifications of heart failure (I–IV) are complementary.

In the United States:

• Heart failure annual incidence increased from 250,000 cases in 1970 to 825,000 cases in 2010, contributing to a prevalence of 5.1 million individuals ≥ 20 years of age.

• Lifetime risk for developing heart failure at the age of 40 years and greater is 1 in 5 in both men and women.

• Between 1979 and 2010, annual heart failure hospitalization rates tripled, with 1,023,000 hospital discharges in 2010.

• In the Medicare population, heart failure is the most common cause for hospitalization.

• After heart failure discharge, readmission rates for recurrent heart failure or other causes are 24% within the first month and 50% within the first 6 months.

• In 2012, direct and indirect medical costs associated with heart failure were $30.7 billion.

• One in 9 deaths includes heart failure on the death certificate.

“The prime candidates for the development of heart failure are patients with hypertension in whom death from stroke has been prevented by antihypertensive therapy and survivors of acute myocardial infarction who have been spared death from arrhythmia.”

—Eugene Braunwald, Shattuck Lecture 1997¹

Heart Failure Recognition

The diagnosis of heart failure may emerge from history, physical examination, or laboratory data.

CLINICAL CRITERIA OF HEART FAILURE

The Framingham study defined useful clinical criteria to identify patients with heart failure (Table 1.1). Patients not fulfilling the Framingham criteria can still have heart failure, albeit less severe disease, if they have symptoms of dyspnea or fatigue associated with structural or functional left ventricular abnormalities.² Specifically, heart failure may be present when an individual has physical limitations at rest or with activity due to inadequate cardiac output or increased left or right ventricular filling pressures. Blood levels of biomarkers, such as B-type natriuretic peptide (BNP), supplement clinical findings to characterize the presence and severity of heart failure.

TABLE 1.1 Framingham diagnostic criteria for heart failure. The diagnosis of heart failure, in the Framingham heart failure study, required two major or one major and two concurrent minor criteria. Minor criteria cannot be attributed to another medical condition.⁴ Source: Adapted from the New England Journal of Medicine, with permission.

MAJOR CRITERIA	MINOR CRITERIA
Acute pulmonary edema	Dyspnea on exertion
Paroxysmal nocturnal dyspnea or orthopnea	Night cough
Neck-vein distention	Tachycardia (> 120 beats/min)
Rales	Pleural effusion
S3 gallop	Hepatomegaly
Abdominojugular reflux	Ankle edema
Cardiomegaly on chest x-ray	Vital capacity decrease (1/3 from max)
Increased venous pressure (> 16 cm H2O)	Weight loss*
Weight loss*

*Weight loss > 4.5 kg 5 days into treatment can be classified as a major or minor criterion

HEART FAILURE CLASSIFICATION

In 1928, the New York Heart Association (NYHA) functional classification was proposed to classify the severity of heart failure based on symptoms.³ In this system, severity ranges from no limitation of functional activity (Class I), slight limitation of functional activity (Class II), marked limitation of functional activity (Class III), to the presence of symptoms at rest (Class IV). Although useful, to characterize a patient’s functional impairment at any point in time and provide an index that correlates with prognosis, the system is limited by the potential for a patient’s class to either worsen or improve rapidly in response to acute exacerbations or treatments (Figure 1.1).

FIGURE 1.1 The ACCF/AHA stages of heart failure compared to the NYHA classification. Whereas NYHA functional class can wax and wane, the ACCF/AHA Stages (A–D) can only advance, usually with greater underlying structural and functional cardiac impairment.

Partly to address this potential for fluctuation in NYHA patient classification, in 2001 the American College of Cardiology Foundation and the American Heart Association published a four-component staging of heart failure in which progression occurs in only one direction encompassing risk factors (Stage A) to end-stage heart disease (Stage D).⁵ This classification was most recently updated in 2013.⁶ The previous New York Heart Association functional class, based solely on symptoms, can still describe the current functional status of a patient in Stages B through D. Especially in Stage C, however, any of the three symptomatic NYHA classifications (Class II, III, or IV) may repeatedly arise, resolve, and recur (Figure 1.2).

FIGURE 1.2 The ACCF/AHA stages of heart failure compared to the NYHA classification. With treatment, a heart failure patient can become asymptomatic, but will remain Stage C.

Stage B is defined as development of structural heart disease in patients who never manifest symptoms or signs of heart failure.⁵ Most patients with a diagnosis of heart failure with either past or current symptoms are considered Stage C. Approximately 1% of patients with heart failure have progressed to an advanced Stage D.²

Epidemiology

Heart failure is increasing, particularly as a disease of aging. T...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Table of Contents
• In Gratitude
• About the Author
• Foreword
• Preface
• Abbreviations
• Introduction
• Chapter 1 HEART FAILURE DIAGNOSIS AND EPIDEMIOLOGY
• Chapter 2 HEART FAILURE PRESENTATIONS AND FUNCTIONAL TYPES
• Chapter 3 STAGE A: PATIENTS AT RISK FOR DEVELOPING STRUCTURAL HEART DISEASE
• Chapter 4 STRUCTURAL HEART DISEASE AND PROGRESSION TO FAILURE: STAGES B, C, AND D
• Chapter 5 STAGE B: ASYMPTOMATIC STRUCTURAL HEART DISEASE
• Chapter 6 ASSESSMENT OF STAGE C PATIENTS WITH HF- r EF
• Chapter 7 ASSESSMENT OF STAGE C PATIENTS WITH HF- p EF
• Chapter 8 STAGE C: IMPROVING OUTCOMES IN SYMPTOMATIC HEART FAILURE
• Chapter 9 STAGE C: THERAPIES FOR ACUTE DECOMPENSATED HEART FAILURE
• Chapter 10 STAGE C: CARDIORENAL SYNDROME
• Chapter 11 STAGE D HEART FAILURE: OPTIONS AND OPPORTUNITIES
• Chapter 12 A PATIENT-ORIENTED PERSPECTIVE TO THE 4 STAGES OF HEART FAILURE
• Appendix A: Glossary
• Appendix B: Summary of Clinical Trials of Therapy
• Index