The Evaluation & Management of Chronic Heart Failure

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines for heart failure define the disease as a chronic impairment in the function of the heart as a pump. In 1928, the New York Heart Association (NYHA) accurately described the signs, symptoms and progression of heart failure. Treatment according to both the ACC/AHA and NYHA guidelines matches treatment to symptoms and severity and seeks to prevent heart failure. Treatment changes step-wise as symptoms get worse.

Heart Failure Basics

• Heart failure typically occurs after some sort of cardiac stress, such as a heart attack or untreated hypertension. The heart works extra hard in response. The left ventricle (LV) of the heart, which pumps blood throughout the body, becomes enlarged and inefficient. LV ejection fraction, the portion of blood that gets pumped out with each beat, decreases. A vicious cycle ensues involving the cardiovascular and renal hormone systems, making the heart work harder and harder. The vicious cycle causes symptoms including shortness of breath, fatigue, and swollen extremities (peripheral edema).

NYHA Heart Failure Classification

• Developed in 1928, the NYHA heart failure classification system primarily considers symptoms caused by physical activity:
  Class I: Ordinary physical activity causes no symptoms.
  Class II: Ordinary physical activity causes symptoms, but they only slightly impair the patient's physical activity.
  Class III: Light physical activity evokes symptoms but symptoms do not occur at rest. Symptoms limit the patient's activity level.
  Class IV: Severe and persistent symptoms, even at rest, worsen with any physical activity.
  Treatments depend on symptom severity.

ACC/AHA Stage System

• To attain greater precision and to refine treatment decisions, the ACC/AHA guidelines include other clinical measures with symptoms:

  Stage A: Patients may not have symptoms or LV enlargement but are at risk due to conditions such as heart attack or untreated hypertension.
  Stage B: Patients may not be symptomatic, but they do have LV enlargement.
  Stage C: Patients are or have been symptomatic in addition to having LV enlargement.
  Stage D: Patients are severely symptomatic despite medical therapy with advanced LV enlargement.

  The clinical appearance of heart failure can vary significantly between individual patients. Physicians should therefore take a detailed medical history. Blood work, EKG, echocardiography and coronary angiography provide important data.

Treatments for ACC/AHA Stage A

• The ACC/AHA guidelines anticipate variations between patients and help doctors determine the best treatments. Class I recommendations include controlling hypertension, cholesterol, blood sugar and thyroid conditions. Patients must avoid predisposing behaviors such as alcohol abuse and smoking. Class IIa treatments include angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor (ARB) blockers in certain patients. Some patients with other medical conditions may need additional medications. Class III, which restricts therapies, recommends that patients not use nutritional supplements to treat or prevent heart failure.

Treatments for ACC/AHA Stage B

• Stage B recommendations include those for Stage A. Further Class I recommendations include using ACE inhibitors, beta-blockers, and/or ARBs in most patients. Doctors should aggressively treat coronary artery disease and heart valve problems. Class IIa and IIb recommendations include an implantable cardioverter-defribilator (ICD) in patients with abnormal heart rhythms. Class III restrictions pertain to avoiding digoxin and calcium channel blockers.

Treatments for ACC/AHA Stage C

• Stage C treatments include those for Stages A and B. Recommendations begin to multiply as treatment becomes more complex and individualized. Other Class I recommendations include adding diuretics and restricting salt intake. When possible, the patient should stop taking certain kinds of medications that can worsen heart failure, such as some kinds of anti-inflammatory drugs, calcium channel blockers, and most antiarrhythmic drugs. The use of ICDs in certain patients moves up to Class I. Certain patients may need additional medications. Class IIa, IIb, and III make specific medication recommendations and restrictions in specific kinds of patients.

Treatments for ACC/AHA Stage D

• Stage D heart failure usually has not responded to treatments thus far. Physicians consider it an end-stage disease, meaning that very little remains to be done aside from transplantation. Recommendations include all those for Stages A to C. Additional recommendations in all classes become increasingly extraordinary and palliative. Class I includes meticulous control of fluid intake, referral for heart transplant, preparation for end-of-life care, and information about inactivating the ICD. Classes IIa, IIb and III pertain mostly to treatments and procedures of possible but limited value.