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ACC/AHA Heart Failure Classification Topic Review
The American Heart Association, American College of Cardiology and Heart Failure Society of America developed a classification of heart failure that divides heart failure into four stages.
The current version of the classification, as presented in the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure, is described below.
Stage A (At Risk for HF)
Stage A is defined as patients at risk for heart failure (HF) who have not yet developed symptoms or biomarkers of cardiac stretch or injury. Stage A patients include those with hypertension, atherosclerotic CVD (ASCVD), diabetes, metabolic syndrome and obesity, genetic variant(s) associated with cardiomyopathy, family history of cardiomyopathy, and those who were exposed to cardiotoxic agents. [Writing Committee Members. J Card Fail. 2022;12a]
Stage B (Pre-HF)
Stage B is defined as patients who show no signs or symptoms of HF but present with evidence of one of the following: [Writing Committee Members. J Card Fail. 2022;12a]
Structural heart disease
- Reduced left or right ventricular systolic function
- Reduced ejection fraction, reduced strain
- Ventricular hypertrophy
- Chamber enlargement
- Wall motion abnormalities
- Valvular heart disease
Evidence of elevated filling pressures
- Invasive hemodynamic measurements
- Noninvasive imaging (eg, Doppler echocardiography) suggestive of elevated filling pressures
Presence of risk factors in addition to:
- Increased B-type natriuretic peptide (BNP) levels* or
- Persistently elevated cardiac troponin*
* In the absence of other conditions which may cause elevation of these biomarkers, including acute coronary syndromes, chronic kidney disease, pulmonary embolus or myopericarditis.
Stage C (Symptomatic HF)
Stage C is defined as structural heart disease in combination with current or previous symptoms of HF. [Writing Committee Members. J Card Fail. 2022;12a]
Stage D (Advanced HF)
Stage D is defined as severe symptoms of HF causing disruption to daily life and recurrent hospitalizations despite attempts to optimize guideline-directed medical therapy. [Writing Committee Members. J Card Fail. 2022;12a]
Note that the ACC/AHA classification is quite different from the New York Heart Association (NYHA) functional classification system, primarily in the fact that regression to prior stages is impossible. Once symptoms develop, Stage C HF is present and the patient cannot revert to Stage B, even if symptoms temporarily subside. By contrast, in the NYHA functional classification, patients can progressively and regressively move between Classes (I to IV), since this classification depends on symptoms alone. [Writing Committee Members. J Card Fail. 2022;doi:10.1016/j.cardfail.2022.02.010;7b]