Heart Failure Stages

Podcast Transcript

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Amanda Vest, MBBS:

Hello, Amanda Vest here. Here are some notes regarding the stages of heart failure that you find in the 2022 AHA/ACC/HFSA guidelines for the management of patients with heart failure. Now, these notes are particularly relevant because they set up much of the terminology and the structure for the treatment of heart failure with reduced ejection fraction, mildly reduced ejection fraction, improved ejection fraction, and preserved ejection fraction. The guidelines have evolved a lot in terms of this staging with a real emphasis on identifying individuals who are at risk for heart failure. This is called Stage A, and so these are persons who have no current or previous signs or symptoms of heart failure and do not show any demonstrable structural or functional abnormalities of their heart. But they have risk factors which have put them at higher likelihood of developing heart failure in the years to come.

And this could include hypertension, known coronary artery disease, could be diabetes, obesity, and the metabolic conditions. It may be that they've been exposed to chemotherapies that are known to be cardiotoxic, for example, or that they're known to be a genetic carrier of a cardiomyopathy gene. So, such patients are really recognized within the heart failure guidelines now, and where appropriate, strategies are suggested that may help to limit their likelihood of progression to actual symptomatic heart failure.

Next, we have Stage B, which can also be described as pre-heart failure. So again, these individuals have not had current or previous signs or symptoms of heart failure, but they do have something such as a structural abnormality. Maybe that's a wall motion abnormality after a myocardial infarction or a reduced ejection fraction. They may have increased filling pressures, for example, a right heart catheterization is done and the wedge is abnormal. Or perhaps they have risk factors along with an increased proBNP, for example, or elevated cardiac troponin in the absence of another explanation for it. So these individuals are felt to be on their way towards developing symptomatic heart failure. And in this setting, there's even more that the guidelines would recommend we consider to improve their future outcomes.

The vast majority of patients that we encounter with heart failure would be termed Stage C. These are individuals with current or previous signs and symptoms of heart failure. So this is really the bulk of our heart failure clinical work.

And then of course, Stage D describes advanced heart failure. So these are individuals who have ongoing heart failure symptoms that interfere with daily life and usually recurrent hospitalizations despite all the attempts to optimize their stability with guideline-directed medical therapies and other appropriate interventions. Patients with Stage D heart failure are those that are being considered for potential evaluation for heart transplantation or mechanical circulatory support, or more so being directed towards palliative strategies to help improve their quality of life.

Within the Stage C group, our arguably largest group that we see clinically as heart failure clinicians, there are different trajectories now identified by the 2022 guidelines. So the management and the way we're thinking about these patients is quite different if they are, for example, a de novo presentation of heart failure versus a person who has presented with symptoms but has now responded to GDMT and has resolution of symptoms, versus a patient with persisting heart failure symptoms or even worsening heart failure symptoms. And these patients with worsening heart failure despite GDMT, maybe an uptick in hospitalizations, I often think of as straddling the gap between Stage C and Stage D. They're often on their way into that Stage D categorization.

Now, defining heart failure and deciding is there an actual diagnosis of heart failure can remain something of a challenge, especially in those individuals with preserved ejection fraction. The 2022 guidelines draw upon a document called Universal Definition of Heart Failure published a year prior. In this definition, the authors seek to clarify and provide a rubric as to how do we determine if a patient actually has heart failure? The patient should have symptoms and/or signs, so symptoms being what the patient reports, signs being what we see on physical examination, of heart failure.

And there has to be a causative structural and/or functional cardiac abnormality. So this could, for example, be a reduced dejection fraction, but in those with a preserved ejection fraction could be the observation of enlarged left atrium or left ventricle, for example. Maybe it's left ventricular hypertrophy on the echocardiogram.

Then this set of criteria must be corroborated by at least one of the following, indicating that the heart failure physiology is underway. So it could either be elevated natriuretic peptides, most commonly the NT-proBNP, or objective evidence of cardiogenic pulmonary or systemic congestion. So this could be a chest x-ray showing pulmonary edema, maybe an echocardiogram showing enlargement of the IVC, or it could be either a resting right heart catheterization or a right heart catheter with exercise indicating abnormalities of the hemodynamics, for example, an elevated pulmonary capillary wedge pressure.

So, the important piece here is that we need the current or prior signs and/or symptoms, some degree of appreciable cardiac structural and/or functional abnormality, and then one of the items that tell us that heart failure pathophysiology is underway and that there's some evidence of congestion, either by lab work imaging, or invasive hemodynamics. Do note that the Universal Definition provides thresholds of natriuretic peptide levels supporting the definition of heart failure. Now again, it isn't sufficient just to have an elevated BNP or NT-proBNP. You have to have the signs and/or symptoms, the structural and functional abnormalities to set up the conditions for diagnosis. So I hope you found these notes helpful.

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