What Are The 4 Stages of Congestive Heart Failure?

Overview of Congestive Heart Failure

Congestive heart failure is a chronic condition that affects approximately 6 million Americans. It is the leading cause of hospitalizations in people over 65. Generally, heart failure occurs when the heart muscle becomes too stiff or weak. As a result, the heart cannot pump blood efficiently to perfuse body organs. This leads to an accumulation of fluids, mostly in the lungs and lower extremities. 

There is no cure for heart failure. Over time, as the heart’s ability to pump reduces, heart failure symptoms become more severe, and you move to the next stage of heart failure. Medications and other treatments can slow down the progression to the advanced stages of congestive heart failure, thus improving the quality of life. 

Types of Heart Failure

• Systolic heart failure or systolic left ventricular dysfunction in which the left ventricle (left-sided bottom chamber) of the heart is weak and cannot pump blood properly to the body. This is called heart failure with reduced ejection fraction or HFrEF.

• Diastolic heart failure or heart failure with preserved ejection fraction (HFpEF), in which the left ventricle becomes stiff and does not fill properly with blood.

• Right-sided heart failure is when the right ventricle (right-sided bottom chamber) is too weak to pump blood properly to the lungs.

• High-output heart failure (rare) in which there is normal heart function but an increased demand by the body, which the heart is unable to meet. 

Causes and Risk Factors

Potential causes of heart failure include coronary heart disease, heart attack, structural heart diseases such as valvular heart disease, arrhythmia (heart rhythm abnormalities), cardiomyopathy, hypertension, diabetes, metabolic syndrome, kidney disease, rheumatic fever, and certain chemotherapy drugs.

Risk factors for heart failure are age over 65 years, family history (close relatives with congestive heart failure), obesity, a high-fat or high-salt diet, lack of exercise, smoking, drinking alcohol excessively, and using recreational drugs like cocaine, which are cardiotoxic. 

Signs and Symptoms of Heart Failure

Symptoms of heart failure may include: 

• Shortness of breath, especially with activity

• Chest discomfort

• Palpitations (fast or irregular heartbeat)

• Tiredness or fatigue

• Swelling in the lower legs, ankles, and feet

• Bloating and weight gain

• Dry hacking cough

• Nocturia (getting up at night to urinate)

• Nausea

• Loss of appetite

Save On Your Heart Failure Medications

What Are The Four Stages of Heart Failure?

As mentioned, heart failure is a long-lasting condition that slowly gets worse over time, requiring lifelong treatment. The American College of Cardiology (ACA) and the American Heart Association (AHA)  classify congestive heart failure into four stages based on the overall heart function and severity of symptoms. 

In addition to the four stages of heart failure based on the ACA and the AHA’s recommendation, healthcare providers also use the New York Heart Association (NYHA) Functional Classification to identify the progression of heart failure based on physical activity limitations. 

Stage A: At Risk

Characteristics of Stage A

In stage A heart failure, the heart is working properly, but there is an increased risk of developing heart failure. This risk may be due to a personal history of medical conditions which are risk factors for heart failure. It can also be due to a family history of congestive heart failure.

Symptoms and Early Warning Signs

In stage A, there is a risk of heart failure, but it is not yet present. There are no symptoms and no limitations in activity. 

Lifestyle Modifications and Treatment for Stage A Heart Failure

• Get regular low-intensity exercise (for example, walking or raking the backyard).

• Stop smoking, alcohol, and recreational drugs.

• Eat a low-sodium, heart-healthy diet.

• Take medications for high blood pressure (for example, angiotensin converting enzyme inhibitors and angiotensin II receptor blocker).

• Take medications for high cholesterol (for example, statins).

• Take medications for diabetes (for example, SGLT2 inhibitors such as dapagliflozin (Farxiga) and empagliflozin (Jardiance).

• Take medications for vascular conditions.

It is worth noting that an important part of the treatment for any stage of congestive heart failure is the treatment of underlying health conditions that cause or worsen heart failure, such as obesity, hypertension, high cholesterol, diabetes, atrial fibrillation, coronary artery disease, lung disease, and kidney disease.

Stage B: Pre-Heart Failure

Characteristics of Stage B

Stage B is the pre-heart-failure stage. The left ventricle has a structural abnormality or is not working normally, but there are no symptoms related to heart failure.

Symptoms

People with stage B heart failure do not have any symptoms or activity limitations.

Lifestyle and Medical Interventions

The treatment for stage B heart failure is the same as stage A, with the use of medications such as angiotensin-converting enzyme (ACE) inhibitors, ARBs (angiotensin receptor blockers), beta-blockers, and aldosterone agonists, depending on ejection fraction and history of heart attacks. 

Surgical procedures may be done to treat coronary artery blockage (narrowing or blockage of the blood vessels that supply blood to the heart), valvular heart disease, or structural heart disease. 

Stage C: Symptomatic Heart Failure

Characteristics of Stage C

Stage C means there is a confirmed diagnosis of heart failure and current or previous symptoms of heart failure.

Common Symptoms

Heart failure symptoms such as shortness of breath, palpitations, chest discomfort, fatigue, leg swelling, fluid retention, weight gain, cough, nocturia (nighttime urination), nausea, and decreased appetite are present. 

Treatment Options and Management Plans

The treatment for stage C heart failure is the same as the treatments for stages A and B. It may include medications and cardiac devices such as:

• Angiotensin-converting enzyme (ACE) inhibitors 

• ARBs (angiotensin receptor blockers)

• Beta-blockers

• Aldosterone agonists

• SGLT-2 (sodium-glucose cotransporter-2) inhibitors 

• Combination of hydralazine and nitrate if you cannot take ACE inhibitors or ARBs

• Diuretics (water pills)

• Angiotensin receptor neprilysin inhibitor (ARNI) drugs such as Entresto (sacubitril/valsartan)

• Anticoagulants or blood thinners for arrhythmia and prevention of blood clots

• Placement of ICD device (implantable cardiac defibrillator)

• Cardiac resynchronization therapy (placement of a biventricular pacemaker)

• Heart surgery for valve replacement 

In addition to medications and cardiac devices, lifestyle changes are as vital for good treatment outcomes:

• Salt restriction 

• Possible restriction on fluid intake

• Daily weight tracking

Stage D: Advanced Heart Failure

Characteristics of Stage D

Stage D is the final and most severe stage of heart failure, also called advanced heart failure. The heart’s ejection fraction is reduced and severe symptoms are present that may not respond to treatment. 

Critical Symptoms

The final stages or last signs of end-stage congestive heart failure may include: 

• Breathlessness with minimal exertion

• Severe swelling due to fluid retention

• Extreme fatigue

• Chest pain

• Irregular heartbeat

• Persistent cough

• Nausea

• Loss of appetite

• Insomnia

• Cognitive impairment (speech and memory problems)

• Depression and anxiety

Comprehensive Treatment Strategies

Stage D treatment is also the same as the previous stages. The stage D treatment plan may also include more advanced treatment options for severe symptoms such as:

• Left ventricular assist device

• Cardiac transplant

• Inotropic drugs that increase the force of heart muscle contractions (for example, digoxin, dobutamine, dopamine, norepinephrine, milrinone, levosimendan) while awaiting a heart transplant or until escalated supportive therapy is being planned.

• Palliative care

Palliative Care and Quality of Life Considerations

Palliative care offers a holistic approach to caring for patients with advanced heart failure. The goal is to improve quality of life alongside medical treatments. Palliative care may include:

• Relief for symptoms like pain, fatigue, shortness of breath, anorexia-cachexia syndrome, and depression.

• Advanced care planning and conversations about end-of-life care, including resuscitation status and use of medical devices.

• Caregiver support to help family members cope with the illness and bereavement.

What Are The New York Heart Association Functional Classification of Heart Failure?

The New York Heart Association (NYHA) functional classification of heart failure is based on limitations of physical activity due to the presence of symptoms such as breathlessness, palpitations, or fatigue. 

Once a patient is diagnosed with stage C or D heart failure, the NYHA Functional Classification is used to place them in one of four categories (classes) as a baseline. While treatment is taking place, healthcare professionals use the NYHA Functional Classification to evaluate how well the treatment is going. 

One key difference between the two heart failure classification systems is that once someone is diagnosed with heart failure, over time, they will move from stage B to C, then, finally, stage D. This progression in the ACC/AHA system signifies a worsening of the condition and a need for more aggressive treatment. 

In contrast, the NYHA Functional Classification is based on a person’s physical limitation. A person’s assigned classification can move up (from class II to class III) as their symptoms worsen, or it can reverse (from class IV to III or even II) if they are responding to treatment, thus improving their function and physical activity. 

• Class I (1): No limitation of physical activity. Ordinary activity levels do not cause any of the symptoms mentioned above (breathlessness, palpitations, or fatigue).

• Class II (2): Slight limitation in physical activity. Comfortable at rest, but typical levels of activity cause symptoms such as shortness of breath, chest pain, fatigue, or palpitation

• Class III (3): Marked limitation in activity. Comfortable at rest, but even low levels of physical activity cause symptoms. 

• Class IV (4): Symptoms are present at rest. Any activity causes symptoms and discomfort.  

Frequently Asked Questions About CHF Stages

How Long Do Most People Live After Being Diagnosed With Congestive Heart Failure?

The average survival rate of CHF is about 50-60% by the fifth year. However, people can live for widely varying amounts of time after being diagnosed with congestive heart failure, depending on the severity of the condition and other factors like age and co-existing health problems. 

What Is The Life Expectancy Of A 75-Year-Old With Congestive Heart Failure?

The life expectancy for a 75-year-old person with average health status and risk factors may be less than 3 years after developing heart failure. In contrast, the life expectancy for a younger person who is under 50 years of age and otherwise low risk may be up to 20 years after a heart failure diagnosis. 

How Long Can You Live With Stage 4 Congestive Heart Failure?

Most people with end-stage heart failure have a life expectancy of less than 1 year, unless they are able to undergo a heart transplant.

What Not To Do If You Have Congestive Heart Failure?

If you have congestive heart failure:

• Do not do strenuous physical activity unless your doctor has allowed it.

• Do not eat an unhealthy diet that is high in salt, sugar, and saturated fats.

• Do not continue smoking if you smoke.

• Do not come in contact with people who are sick. 

What Are The Final Stages of Congestive Heart Failure?

The final stage of congestive heart failure includes severe symptoms and the need for around-the-clock care, including palliative care. Treatment options may include implantable cardioverter-defibrillators, ventricular assist devices, and heart transplants.

How Do Doctors Diagnose Heart Failure?

Doctors can do a variety of tests to diagnose heart failure, including:

• Electrocardiogram (EKG) to record the electrical activity of the heart.

• Echocardiogram to create images of the heart using sound waves and measure how well it's pumping blood.

• Stress tests to see how the heart works during physical activity and whether you experience symptoms while active.

• Chest X-ray to view the heart and lungs.

• Blood tests to check for proteins that are increased in people with heart failure.

• Lung function tests to check if a lung problem is contributing to breathlessness.

• Imaging tests such as a cardiac CT scan, cardiac MRI, or nuclear heart scan to visualize the heart and see how well it is working.

• Cardiac catheterization with coronary angiography to see if the arteries supplying blood to the heart are blocked.

Living With Congestive Heart Failure

Tips for Managing CHF: What is the Treatment for the Different Stages of Heart Failure?

Lifestyle changes, medications, and surgical procedures are used to treat heart failure. The treatment plan is different for each person and depends on the underlying cause and symptoms. If you are at risk of heart failure or have been diagnosed with heart failure, it is important to go for regular medical checkups as advised by your healthcare provider. 

Lifestyle Changes for Heart Failure

According to the American Heart Association, the following lifestyle changes reduce the symptoms of heart failure, slow the progression of the disease, and improve your overall quality of life in all four stages of heart failure:

• Quit smoking: Tobacco smoke raises blood pressure and heart rate. Chemicals in cigarettes also reduce the delivery of oxygen to vital organs such as the heart and brain. Other negative health effects of smoking include decreased levels of HDL (good) cholesterol, an increased risk of blood clots, and a decreased ability to exercise.

• Remain physically active: Doctors advise heart failure patients to get regular, moderate exercise such as walking or doing yard work. This helps your heart muscle get stronger. Work with your cardiac rehab team to develop a safe and effective exercise plan. If exercise is not an option for you, you may benefit from rehabilitation exercises.

• Get enough rest: While it’s important to be physically active, it’s also important to get enough rest, including restful sleep at night as well as daytime naps. This gives your heart a chance to rest.

• Manage stress: Stress and anxiety can cause you to breathe heavily and make your heart pump harder. Practice mindfulness, meditation, deep breathing, and low-intensity exercises such as yoga and tai-chi to manage stress.

• Eat a healthy diet: A low-fat, low-salt diet can support heart health. Talk to your healthcare provider about the DASH eating plan. 

• Track fluid intake: People with heart failure retain fluid in their bodies. They are often prescribed diuretics (water pills) to remove excess fluid in urine. Talk to your healthcare provider about how much fluid is healthy for you. Keep a record of how much you’re drinking. Your provider may also ask you to measure urine output.

• Monitor your weight: Weigh yourself each morning, preferably before urinating and before breakfast, wearing the same or similar clothes on the same weighing scale. Bring a log of your body weights to your healthcare appointments. This will help your healthcare provider adjust your heart failure medications. Tell your doctor right away if you gain more than 5 pounds within a few days. 

• Avoid sick contact: People with heart failure are at an increased risk of complications from infections such as the flu and pneumonia. To lower your risk of respiratory infections, avoid contact with people who are sick, stay away from crowded places, wash your hands regularly with soap and water, and avoid touching your face with your hands. Talk to your healthcare provider about getting the annual flu vaccine and single-dose pneumococcal vaccine.