These Are the 4 Stages of Heart Failure
Heart failure is very common—and it just doesn't happen to older people. About 6.2 million Americans over the age of 20 have it. These are the stages of heart failure and what you should know about them.
What is heart failure?
Heart failure doesn’t mean the heart has stopped beating. Quite simply, heart failure happens when the heart muscle can’t pump enough blood to supply the body’s needs. And it can happen to anyone—even if you have a healthy lifestyle or never had a heart attack.
An inherited heart condition, or a poorly managed disease such as diabetes which can damage the heart, could nudge you into a higher risk status. What’s not as easy to comprehend is that heart failure is multifaceted. It can be mild, with no symptoms, or it can be quite severe in which a patient needs a heart transplant to survive.
It’s usually a long-term, chronic condition, although it can come on suddenly. It often gets worse, but not always. Sound confusing? Keep reading to learn about the four different stages and what each stage could mean for your heart.
Why four stages?
While the term “heart failure” has been around forever, the stages of heart failure have not.
“The classification of heart failure into four stages is fairly new and used specifically by the heart failure community—not by the lay public and rarely even by most cardiologists. These stages were established to emphasize the importance of prevention of heart failure,” says Michele Hamilton, MD, cardiologist, and director of the Advanced Heart Failure Program in the Smidt Heart Institute at Cedars-Sinai in Los Angeles.
(Here are tips for how to prevent heart disease.)
How the four stages are determined
Doctors use two types of classifications system to determine the ideal therapy for a heart failure patient. The American College of Cardiology (ACC) and the American Heart Association (AHA) have four stages (A-D).
The AHA classification system relies on objective evidence from various types of cardiac testing that demonstrates the heart is not working properly and the likely prognosis. The system can indicate that the heart muscle is at high risk of weakening and could lead to multi-organ dysfunction, says Hugh Parker, MD, a cardiologist with UCHealth Heart and Vascular Center, in Cherry Creek, Colorado and an assistant professor with the CU School of Medicine in Aurora, Colorado.
The New York Heart Association (NYHA) has four classes of heart diseases. The NYHA complements the ACC/AHA as it describes the patient’s symptoms in relation to ordinary physical activity and includes the patient who doesn’t have heart failure but is at a high risk of developing it.
Defined as: At high risk for heart failure but without structural heart disease (defects in the heart from aging, injury, infection, or heart defect at birth), or symptoms of heart failure.
Considered the pre-stage, stage A denotes a healthy heart that is functioning normally.
“We use “stage A” to define the group of people with risk factors, such as family history of heart failure, personal history of diabetes, high blood pressure, or coronary artery disease that increase their risk of developing heart failure in the future,” says Ameya Kulkarni, MD, an interventional cardiologist at Kaiser Permanente in Tysons, Virginia, and chair of the Mid-Atlantic Kaiser Permanente Cardiovascular Institute.
Symptoms of stage A
By definition, there are no symptoms to stage A heart failure, but it is vital for people with underlying risk-factors to monitor their risks. That might mean staying on top of managing blood sugar in diabetes or keeping cholesterol levels in check.
Diagnosing stage A
Stage A is diagnosed by risk factors including any health conditions a patient might already have, such as diabetes, high blood pressure, high cholesterol, or a family history of heart failure. (Here are the things doctors do for themselves to lower high cholesterol.)
Treatments for stage A
There are no symptoms to treat in stage A, but as Dr. Kulkarni mentioned, managing the risk-factors is key, so stage B doesn’t sneak up on you (more on this later). Managing risk factors could significantly reduce your chance of developing these types of heart disease.
Managing and living with stage A
Stage A might not immediately impact your health because it has no symptoms. But, symptoms could develop and progress to later stages of heart failure if you don’t properly manage your risk factors. Stage A is the perfect time to embrace a heart-healthy lifestyle to prevent future complications, Dr. Kulkarni says.
“This includes eating a diet low in salt and low in fat, rich in fruit and vegetables, and proteins like fish or chicken, knowing your blood pressure and blood sugar, and discussing medications with your doctor where appropriate to treat high blood pressure, diabetes, or high cholesterol,” says Dr. Kulkarni.
And don’t forget about exercise. Dr. Kulkarni recommends regular aerobic exercise totaling 150 minutes per week.
(New to exercise? Try this four-week walking plan. Just be sure to get clearance from your doctor first.)
What is the prognosis for stage A?
“As long as your risk factors are under control and you follow these tips for a healthy lifestyle, the prognosis for stage A heart failure is excellent,” Dr. Kulkarni says.
(Here are the ways heart doctors protect their heart health.)
Defined as: Structural heart disease with no symptoms or signs of heart failure. In stage B, there is evidence of structural abnormalities in the heart, which might include conditions like heart valve malfunction, blockage in the heart arteries, abnormal thickening of the heart, or a decrease in the strength of the heart’s squeeze function, Dr. Parker says.
Yet, even though these conditions might not have noticeable symptoms you might associate with heart trouble, like shortness of breath or chest pain, they can certainly lead to more severe symptoms and symptomatic failure of the heart.
Symptoms of stage B
“Patients in this classification are asymptomatic but at high risk of progressing to symptomatic disease, including stages C and D,” says Dr. Parker.
As with stage A, it is essential to stay on top of existing conditions such as high cholesterol levels or high blood pressure. When they aren’t managed well, high blood pressure causes damage to the arteries, and high cholesterol levels can cause blockage in the arteries affecting blood flow to the heart.
Diagnosing stage B
Since there are no symptoms of heart failure in this stage, heart failure could easily be missed until it progresses to a more serious status. There are many tests to assess heart failure causes, but the first diagnostic tests might include an electrocardiogram or a blood test to see if certain hormones are present that stem from a weakened heart. Sometimes more direct information is needed, Dr. Parker says. An echocardiogram, for example, checks for structural changes.
“We may recommend a heart catheterization where pressures in the heart are directly measured by small tubes we place in the heart through the arteries and veins,” he says.
Treatments for stage B
Treating heart failure in stage B includes the same treatments for stage A as well as medication or more cardiac-specific medications and procedures, such as artery and valve repair. Some of the medications may include ACE inhibitors, beta-blockers, ARB, ARNI, diuretics, and potassium supplements.
People with coronary artery disease (blocked heart arteries) may need angioplasty or stent placement (a tiny metal mesh coil or tube) to help widen an artery and improve blood flow to the heart.
Treatment might be necessary for the existing structural heart diseases found in stage B, too. As mentioned before, structural heart disease may stem from defects in the heart from aging, injury, infection, or defect at birth.
For instance, a weakening or thickening of the heart muscle might be as simple as getting the patient on the right medications, says Dr. Parker. “In patients with blockages in the arteries, treatment might be as complex as coronary artery bypass grafting surgery,” he says.
Coronary artery bypass grafting surgery for patients with blockages in the heart arteries involves using an artery in the chest wall, or removing veins from the legs, and grafting them to coronary arteries. This helps redirect blood flow to the heart muscle.
Managing and living with stage B
Healthy living is the best approach to managing stage B heart failure, Dr. Parker says. “Most underlying conditions will benefit from a plant-based or Mediterranean diet, dietary sodium restriction, tobacco cessation, and increased regular physical activity.”
That’s a smart way to live regardless of heart failure, but it’s prudent to fine-tune a care plan according to the specific health issue (like high blood pressure) going forward.
“Tailoring treatment and lifestyle changes to each underlying condition is a complex process that is not one size fits all,” says Dr. Parker.
What is the prognosis for stage B?
As there are many underlying conditions with stage B heart failure, there can also be many different prognoses.
“Unlike staging in cancer, which refers to the stage of a particular disease, stage B heart failure includes a broad array of underlying conditions, all tied together by the collective tendency to cause progression to the symptomatic weakening and failure of the heart,” says Dr. Parker.
Take high blood pressure for example. With the right medical therapy and lifestyle, Dr. Parker says it can more or less “be cured.” But a genetic heart condition such as familial dilated cardiomyopathy, in which the heart muscle becomes thin and weak, carries an annual mortality rate is 10 percent or higher.
Defined as: Structural heart disease with prior or current symptoms of heart failure. Stage C heart failure is a serious matter that often alters daily life.
“There is both heart damage and symptoms—that is, the heart has become weak and does not squeeze well, and the symptoms of heart failure (shortness of breath, fatigue and exercise intolerance) have also developed,” says Monica Colvin, MD, a board-certified cardiologist in advanced heart failure and transplant cardiology at the Michigan Medicine Frankel Cardiovascular Center in Ann Arbor.
Symptoms of stage C
The common symptoms of stage C heart failure are difficulty breathing—especially with exertion, tiredness, and low exercise tolerance. “Patients may also develop swelling in the ankles, legs or abdomen, dizziness or light-headedness, or decreased mental sharpness,” says Dr. Colvin.
Diagnosing stage C
“Echocardiogram is the most common test used to evaluate the heart function and whether there is heart failure,” says Dr. Colvin. Other studies utilized to diagnose heart failure include an MRI, MUGA [multigated acquisition] scan (a noninvasive test to assess heart function), or nuclear stress test, which uses radioactive dye and an imaging machine to get a closer look at the blood flowing to the heart.
Treatments for stage C
Stage C is treated with a combination of medications known as guideline-directed medical therapy (GDMT). “Heart failure therapy has been shown to prevent heart failure from getting worse and to improve survival,” says Dr. Colvin.
- ACE (angiotensin-converting enzyme) inhibitors, ARBs (angiotensin receptor blockers), or ARNIs (angiotensin receptor neprilysin inhibitor) to treat high blood pressure and heart failure
- Beta-blockers to help slow down heart rate and pump blood more efficiently, and allows the heart to preserve strength
- MRAs (mineralocorticoid receptor antagonist) to remove excess fluid and loss of potassium
- Ivabradine, which is useful in slowing down heart rate and reducing hospitalization in some patients
In addition to these medications, Dr. Colvin says, “Hydralazine and nitrates added to the above helps improve survival rate in African American patients with heart failure.”
(Note that while guidelines differentiate treatment for African American patients, race-based medicine is considered somewhat controversial, as per reports from the American Medical Association and the American Family Physician.)
Diuretics (water pills) might be given for patients who retain fluid and digoxin for patients who continue to have heart failure symptoms. Implantable devices, such as a pacemaker or defibrillator, protect against dangerous heart rhythms. Cardiac rehabilitation (a type of monitored exercise) is also often prescribed to help heart failure patients.
Living with stage C heart failure
It’s vital to take-charge of stage C heart failure and abide by the treatment plan your doctor issues. Even if you often feel fine, untreated, stage C can progress and become much worse. Patients might develop arrhythmias or have reduced cardiac output—meaning the heart isn’t pumping enough blood to meet the body’s demands. When that happens, vital organs such as the kidneys could be damaged.
Heart failure often prompts the body to retain salt and fluid, so eating a low salt diet to prevent swelling and fluid retention is advised. In advanced cases of heart failure, even fluids are restricted. “Patients are also asked to abstain from alcohol due to its effect on the heart and on the rhythm of the heart,” says Dr. Covin.
What is the prognosis for stage C
“The five-year survival of stage C heart failure is 75 percent, however, heart failure therapy is very successful in preventing the progression of heart failure,” says Dr. Colvin.
Heart failure therapy includes taking medications as prescribed. It might mean surgery to implant devices such as an ICD (internal cardioverter defibrillator) to stop life-threatening heart rhythms or a pacemaker to help your heartbeat in a normal sequence.
And of course, embracing lifestyle changes that make it easier on your heart to function such as making these heart-healthy meals that cardiologists cook.
Defined as: Refractory heart disease (symptoms significantly limit daily life despite treatment), requiring specialized interventions.
Stage D is the most severe stage of heart failure. “In these patients, the pumping function of the heart is often severely reduced and not meeting the needs of the other organs,” says Stephen Greene, MD, a cardiologist specializing in heart failure and assistant professor of medicine at Duke University School of Medicine in Durham, North Carolina.
Symptoms of stage D
Stage D’s symptoms are the same as stage C—shortness of breath, fatigue, swelling in legs and abdomen, etc., and likely more severe. “Patients often have a history of multiple hospitalizations for worsening heart failure symptoms,” says Dr. Greene.
Diagnosing stage D
In addition to the symptoms of heart failure and hospitalizations, various diagnostic testing is done.
“To further confirm the diagnoses, patients often undergo heart catheterizations to measure the pressures and pumping function of the heart. Other patients may undergo stress testing that shows severe impairment in exercise capacity due to the poor heart function,” says Dr. Greene.
Treatments for stage D
There are three broad categories for treating stage D heart failure. “Treatment options include heart transplantation, mechanical heart pumps (left ventricular assist devices), and intravenous medications that force the heart to pump harder,” says Dr. Greene.
The type of treatment option is tailored to each patient and a shared decision-making process between the patient and the doctors involved.
“Each of these options has its own unique set of advantages and disadvantages,” says Dr. Greene. “For purposes of maximizing life expectancy and improving symptoms, having a heart surgery with heart transplantation or mechanical heart pump have the best data. Intravenous medications may temporarily improve symptoms, but are not proven to make the patient live longer,” he says.
Living and managing stage D
While the treatment options have evolved and improved over the years, the treatment’s success still heavily depends on the level of commitment and the significant lifestyle changes that need to be met by the patient. For example, Dr. Greene says patients receiving heart transplantation must continuously take medications to suppress the immune system and prevent the immune system from rejecting the new heart.
“Details of how to take care of the different therapies and the potential side effects are discussed at length prior to either surgery and understanding what is involved is an important part of deciding which therapy is best for which patient,” he adds.
(Here are the things cardiologists won’t tell you.)
The average survival rate (and quality of life) improves significantly for patients who undergo heart transplantation or a mechanical heart pump placement. At one year, survival is approximately 90 percent, Dr. Greene says. Without heart transplantation or a mechanical heart pump, most patients with stage D heart failure die within a year, he says.
The last word
Heart failure can become a life-threatening condition if left untreated. Living with heart failure means staying on top of your heart health with healthy lifestyle habits and treatment to prevent further complications. Remember, this chronic condition can happen to anyone.
If you believe you’re experiencing symptoms related to heart problems, contact your doctor for further support.
Next, here are the best heart-healthy products for your home.
- Centers for Disease Control and Prevention: "Heart Failure"
- Heart Failure Society of America: "Learn About Heart Failure"
- Penn Medicine: "Heart Failure Classification: Stages of Heart Failure and Their Treatments"
- Michele Hamilton, MD, cardiologist, and director of the Advanced Heart Failure Program in the Smidt Heart Institute at Cedars-Sinai in Los Angeles
- Hugh Parker, MD, a cardiologist with UCHealth Heart and Vascular Center, in Cherry Creek, Colorado and an assistant professor with the CU School of Medicine in Aurora, Colorado
- Ameya Kulkarni, MD, an interventional cardiologist at Kaiser Permanente in Tysons, Virginia, and chair of the Mid-Atlantic Kaiser Permanente Cardiovascular Institute
- Monica Colvin, MD, a board-certified cardiologist in advanced heart failure and transplant cardiology at the Michigan Medicine Frankel Cardiovascular Center, Ann Arbor
- Stephen Greene, MD, a cardiologist specializing in heart failure and assistant professor of medicine at Duke University School of Medicine, Durham, North Carolina
- American Medical Association: "Race-based medicine is wrong. How should physicians oppose it?"
- American Family Physician: "Race-Based Treatment Decisions Perpetuate Structural Racism"