4 Stages of Congestive Heart Failure: What Each Stage Means

Angela Ryan Lee, MD
·8 min read
6

Medically reviewed by Anisha Shah, MD

Congestive heart failure (CHF) is a condition in which the heart isn't able to effectively pump blood to the body, leading to symptoms like shortness of breath, swelling, and fatigue. The American College of Cardiology/American Heart Association (ACC/AHA) uses a staging system for CHF, known as ACC/AHA staging.

Within this system are stages A through D, with A being at risk for heart failure and having no symptoms and D being advanced heart failure. As heart failure progresses from one stage to the next, life expectancy decreases.

This article will discuss the four stages of heart failure, its treatment, and prognosis.

Stage A: At Risk for Congestive Heart Failure

In stage A heart failure, there are no symptoms or identified problems with the heart, but there are risk factors for heart failure. Some risk factors are out of a person's control, like genetics or family history of heart failure. Some risk factors that may be modified include:

  • High blood pressure

  • Diabetes

  • Coronary artery disease

  • Having obesity

In addition, exposure to some medications or toxic substances place you at higher risk for heart failure. This includes things like radiation and certain chemotherapy agents used for cancer treatment, as well as alcohol and drugs like cocaine or methamphetamines.



Progression and Life Expectancy

Stage A heart failure, meaning a person is at risk that can progress to later stages, is very common since risk factors are prevalent. For example, high blood pressure affects nearly half of the U.S. population.

One study that followed 413 patients with stage A heart failure over four years found that 35% progressed to stages B or C heart failure in that time frame.

Life expectancy with stage A heart failure varies greatly depending on age, overall health, and other underlying conditions. Survival rates aren't typically reported for stage A heart failure, but an older study, from 2007, did find a 97% five-year survival for people with stage A heart failure.



Treatment

Management of stage A heart failure involves aggressive lifestyle modifications, such as blood pressure, blood sugar, and cholesterol control, as well as eating a heart-healthy diet, getting regular physical activity, and avoiding smoking or drinking alcohol in excess.

Stage B: Pre-Heart Failure

In stage B heart failure, also known as pre–heart failure, there are abnormalities in the heart, but they are not yet significant enough to cause symptoms. There is evidence of structural or functional abnormalities in the heart, such as:

  • Valve problems

  • Thickening of the heart wall

  • Problem with the heart filling (diastolic dysfunction)

  • Reduced pumping function, as measured by the ejection fraction (reduced ejection fraction, also called systolic heart failure, is when the heart muscle does not contract effectively and can’t carry enough oxygen-rich blood throughout the body)

  • Elevated cardiac biomarkers, such as B-type natriuretic peptide (BNP)



Progression and Life Expectancy of Stage B Heart Failure

Over time, stage B heart failure can progress to symptomatic heart failure (stages C and D). In a study of preclinical heart failure involving 413 people with stage B heart failure, 6% progressed to symptomatic heart failure over four years.

A 2007 study found a 95.7% five-year survival rate for stage B heart failure. However, progression and survival are worse when looking at a specific subset of stage B heart failure. People with reduced ejection fraction are more likely to progress to symptomatic heart failure and had worse survival rates.



Treatment of Stage B Heart Failure

Treatment of stage B heart failure, as with stage A, includes aggressive risk factor modifications. In addition, certain medications may be beneficial in people with stage B heart failure, such as those with reduced ejection fraction or those with a history of heart attack. Depending on the individual, these may include:

  • Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)

  • Beta-blockers

  • Statins

Stage C: Symptomatic Heart Failure

Stage C, or symptomatic heart failure, is what most people think of as congestive heart failure. In stage C heart failure, there is an impairment of the heart that is causing symptoms, which may include:

  • Fatigue

  • Shortness of breath

  • Difficulty breathing when lying down flat

  • Waking up at night short of breath

  • Cough

  • Swelling in the lower extremities or abdomen

  • Weight gain

  • Palpitations

  • Light-headedness

  • Decreased appetite or feeling full sooner when eating



New York Heart Association Classification

Another classification system used in heart failure is the functional class, which is related to symptom severity and impact on daily life. This is known as the New York Heart Association Classification and includes:

  • Class 1: No impairment in physical activity

  • Class 2: Ordinary activity that causes mild symptoms, slight limitations in activity, no symptoms at rest

  • Class 3: Significant limitations due to symptoms with activity, no symptoms at rest

  • Class 4: Symptoms at rest, worsened with any physical activity

The ACC/AHA staging system often is combined with the NYHA class to provide a more detailed description of a particular person. For example, someone with stage C, NYHA class 2 heart failure, has symptomatic heart failure with a mild impairment of physical activity.





Progression and Survival in Stage C Heart Failure

Stage C heart failure can be stable for many years or can progress to stage D heart failure. One study found that over a three-year time frame, 4.5% of people with stage C heart failure with reduced ejection fraction progressed to stage D heart failure.

Overall five-year survival in stage C heart failure is about 75%, meaning 3 in 4 people are alive after five years. However, this varies by age and other underlying conditions.



Treatment

Treatment of stage C heart failure includes a number of medications depending on the individual situation:

Some people who have reduced ejection fraction may also benefit from placement of an implantable cardioverter-defibrillator (ICD).

Stage D: Advanced Heart Failure

Stage D Heart failure, also known as advanced heart failure or end stage heart failure, is the most severe form of heart failure, with significant symptoms that impact daily life and frequent hospitalizations despite medical treatment. Life expectancy is poor in people with stage D heart failure, which comes with a 20% five-year survival.

Treatment of Stage D Heart Failure

Treatment includes the same medications used in stage C heart failure, however they may not be tolerated well in stage D heart failure due to low blood pressure or side effects. In stage D heart failure, the following additional treatments may be considered:

A cardiologist, typically a cardiologist specializing in heart failure conditions, can discuss any advanced therapies such as LVAD or transplant that may be an option, taking into account your individual preferences and goals. Palliative care can be very helpful in managing symptoms and planning treatment and end-of-life concerns, regardless of whether advanced therapies are pursued.

How Quickly Does CHF Progress From Stage to Stage?

The progression of heart failure from stage to stage varies greatly and is not very predictable. Some people may never progress from stage A, whereas others might progress rapidly or over a period of many years. It all depends on the underlying cause of heart failure and other risk factors.

There are several models that assess risk that your cardiologist may use to help predict prognosis based on individual risk factors.



How to Prevent Heart Failure Progression

Progression of heart failure is not always in our control, but there are some things to do to keep the heart as healthy as possible. These include:

  • Getting regular physical exercise

  • Eating a heart-healthy diet, rich in fruits, vegetables, legumes, beans, and whole grains; and low in sodium, processed foods, trans fats, and sugars

  • Avoiding cigarette smoke

  • Controlling blood pressure, cholesterol, and blood sugar

  • Taking medications as directed by your healthcare provider



Coping with End-Stage Congestive Heart Failure

End-stage heart failure significantly impacts daily life, and it's important to work with your healthcare team to come up with a plan to help control symptoms and improve quality of life. Having a good support system and plan is important, and a palliative care team can play a great role in managing symptoms and planning.

Discuss with your care team if you are experiencing worsening symptoms, medication side effects, or symptoms of depression or anxiety since some medications or adjustments can be made to help you feel better.

Summary

Congestive heart failure is classified into four stages using the ACC/AHA staging system, which ranges from A to D. As heart failure progresses, symptoms appear and worsen, and life expectancy decreases. A cardiologist can help come up with an appropriate treatment plan to reduce your risk of heart failure progression and improve survival according to your individual circumstances.

Things to do to maintain a healthy heart include eating a heart-healthy diet, getting regular physical exercise, quitting smoking, and avoiding excessive alcohol.

Read the original article on Verywell Health.