You’re listening to ReachMD. This medical industry feature is titled “Heart Failure Disease State Awareness.” Here is your guest, Dr. Nancy Albert.
Welcome everyone and thank you for listening today to the third podcast in our heart failure series. My name is Dr. Nancy Albert. I am the associate chief nursing officer for the Office of Nursing Research and Innovation within the Cleveland Clinic health system and a clinical nurse specialist for the Kaufman Center for Heart Failure at the Cleveland Clinic main campus in Ohio.
Last time, my colleague, Dr. Steven Greene, discussed the pathophysiology of heart failure with reduced ejection fraction compared to heart failure with preserved ejection fraction. Today, we will discuss heart failure disease state awareness. Today we will review the joint American College of Cardiology and American Heart Association, or ACC/AHA, stages of heart failure, how heart failure is classified based on left ventricular ejection fraction, and the New York Heart Association, or NYHA, heart failure functional classifications.
This podcast is supported by and made on behalf of Boehringer Ingelheim Pharmaceuticals, Inc. and Lilly USA, LLC. Content discussed during this podcast has been reviewed for consistency with FDA guidelines and is not approved for continuing medical education credit.
I’d like to start with a review of the stages of heart failure as defined by the ACC/AHA.
There are 4 stages of heart failure, ranging from at risk for heart failure to having advanced disease. These stages were created by the ACC and AHA and were given letter titles (A, B, C, and D). Therapeutic interventions in each stage aim to modify risk factors (that would be stage A), treat risk and structural heart disease to prevent HF (in stage B), and reduce symptoms, morbidity, and mortality (in stages C and D).
The risk factors associated with developing heart failure include hypertension, a genetic variant or a family history of cardiomyopathy, diabetes, obesity, and coronary artery disease, to name a few. A person with stage A heart failure has a higher risk of developing heart failure compared with the general population. These adults do not have current or previous heart failure symptoms, nor do they exhibit structural or functional heart disease or abnormal biomarkers; they have risk factors that could lead to heart failure, some of which are modifiable.
Like patients in stage A, stage B patients do not have current or previous symptoms of heart failure, but they do have evidence of 1 of 3 conditions: structural heart disease, increased filling pressures, and risk factors and increased natriuretic peptide levels or persistently elevated cardiac troponin in the absence of competing diagnoses. Because of these 3 major characteristics, stage B is often referred to as “pre–heart failure.” Stage B differs from stage A in that the heart presents with one or more of these.
Stage C, or symptomatic heart failure, as the name suggests, is when the patient has current or previous signs/symptoms of heart failure.
Stage D is the most severe of the heart failure stages. People in stage D will have significant symptoms that can cause severe limitation in carrying out activities and they even have symptoms at rest, resulting in recurring hospitalizations despite attempts to optimize guideline-directed medical therapy.
An additional way to classify heart failure is based on function. Specifically, the condition can be classified by left ventricular ejection fraction. Patients with
a left ventricular ejection fraction less than or equal to 40% are classified as having heart failure with reducedejection fraction.
Adults with a left ventricular ejection fraction of 41% to 49% are classified as having heart failure with mildly reduced ejection fraction.
Importantly, adults who exhibit a baseline left ventricular ejection fraction of 40% or less and then a follow-up left ventricular ejection fraction of greater than 40% are still classified as having heart failure, but with the caveat that they have improved ejection fraction.
And adults with left ventricular ejection fraction at or above 50% are classified as having heart failure with preserved ejection fraction.
The NYHA further subclassifies patients with symptomatic or advanced heart failure (meaning thought adults who are in ACC/AHA stages C or D) into 4 categories. The NYHA functional classification has long served as a prognostic tool for heart failure and determines clinical trial eligibility and candidacy for drugs and devices.
There are 4 NYHA classes, as follows:
- Patients in class I have no limitation of physical activity; ordinary physical activity does not cause heart failure symptoms in patients at this stage
- In class II, there is a slight limitation of physical activity; the patient is comfortable at rest, but ordinary physical activity results in heart failure symptoms
- With class III, we see a marked limitation of physical activity; the patient is comfortable at rest, but less than ordinary activity causes heart failure symptoms
- Finally, in class IV, patients are unable to carry on physical activity and have heart failure symptoms with any physical activity or while at rest
Heart failure is a serious chronic condition that is poorly recognized. Creating awareness about how heart failure is staged will allow adults to receive a timely diagnosis and appropriate treatment.
Thank you all for joining me today.
As we have discussed, there are various ways to classify heart failure based on cardiac structure and function. Understanding how these classification systems work will increase disease state awareness and greatly benefit our patients with heart failure and their caregivers.
I hope you’ll join my colleague, Dr. Pam Kushner, for the next chapter in our heart failure podcast series, as she discusses how healthcare providers can accurately diagnose heart failure.
This program is part of a 6-part series supported by and created on behalf of Boehringer Ingelheim Pharmaceuticals, Inc. and Lilly USA, LLC. If you missed any part of this discussion and would like to access the other episodes in this series, visit reach-m-d-dot-com-slash-industry-feature. This is ReachMD. Be part of the knowledge.