Congestive heart failure classification

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Congestive Heart Failure Microchapters


Patient Information


Historical Perspective



Systolic Dysfunction
Diastolic Dysfunction


Differentiating Congestive heart failure from other Diseases

Epidemiology and Demographics

Risk Factors


Natural History, Complications and Prognosis


Clinical Assessment

History and Symptoms

Physical Examination

Laboratory Findings


Chest X Ray

Cardiac MRI


Exercise Stress Test

Myocardial Viability Studies

Cardiac Catheterization

Other Imaging Studies

Other Diagnostic Studies


Invasive Hemodynamic Monitoring

Medical Therapy:

Acute Pharmacotherapy
Chronic Pharmacotherapy in HFpEF
Chronic Pharmacotherapy in HFrEF
ACE Inhibitors
Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Positive Inotropics
Angiotensin Receptor-Neprilysin Inhibitor
Antiarrhythmic Drugs
Nutritional Supplements
Hormonal Therapies
Drugs to Avoid
Drug Interactions
Treatment of underlying causes
Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.[2],


Heart failure may be classified based on several classification systems.


Several classification systems are used to characterize heart failure according to the: [1] [2]

  • The pathophysiology of heart failure:
    • Systolic vs diastolic heart failure
    • Left-sided, right-sided or biventricular heart failure
    • Low output vs high output heart failure
  • The underlying physiology based on left ventricular ejection fraction:
  • The chronicity of heart failure:
    • acute or chronic
  • The severity of symptoms of heart failure:
    • New York Heart Association Class (NYHA class)
    • Killip class (severity of the symptoms in the acute setting after myocardial infarction)
  • The stage (progression of the disease) of congestive heart failure:
    • The American College of Cardiology Foundation/American Heart Association (ACCF/AHA) classification: A, B, C, D.

1. Systolic versus Diastolic Heart Failure

2. Left-, Right- and Biventricular Failure

Another common method of classifying heart failure is based upon the ventricle involved.

  • Left-ventricular Heart Failure: There is impaired left ventricular function with the reduced flow into the aorta.
  • Right-ventricular Heart Failure: There is impaired right ventricular function with the reduced flow into the pulmonary artery and lungs.
  • Biventricular Failure: The most common cause of right heart failure is left heart failure, and mixed presentations are common, especially when the cardiac septum is involved.

3. High output versus Low output Heart Failure

4. Classification of Heart Failure Based on the Ejection Fraction (EF)

  • The 2013 ACC/AHA guideline and 2017 ACC/AHA/ HFSA Focused Update of the 2013 ACCF/AHA Guideline classified heart failure into heart failure with preserved (HFpEF), and reduced ejection fraction (HFrEF).
  • The 2016 European society of cardiology (ESC) guideline classifies heart failure into heart failure with preserved (HFpEF), mid-range (HFmrEF) and reduced ejection fraction (HFrEF).

5. Chronicity of Heart Failure

  • Acute or Decompensated: Acute or decompensated heart failure is a term used to describe exacerbated or decompensated heart failure, and refers to an episode in which a patient sustains a change in heart failure signs and symptoms that necessitates urgent therapy or hospitalization.[4]
  • Chronic: There is stable symptomatology in chronic heart failure.

6. The Severity of Heart Failure

The NYHA functional classification is used to describe the severity of symptoms and exercise intolerance in patients with congestive heart failure.

The New York Heart Association Criteria (NYHA)
NYHA Class Definition
NYHA I No symptoms with ordinary activity

Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or angina.


Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.

NYHA IV Unable to carry out any physical activity without discomfort. Symptoms are present at rest.

7. The Stages of heart failure

The ACC/AHA classification system was introduced to emphasize the natural history of the heart failure syndrome and to identify opportunities to intervene earlier and prevent disease progression.

ACC/AHA Classification of Chronic Heart Failure Based on the Structural and Symptomatic Stages of the Syndrom
Stages Definition Example Corresponding NYHA class
A Patient at high risk for developing HF but without structural heart disease or symptoms of heart failure None
B Patient with structural heart disease who has never developed signs/symptoms of HF NYHA class I
C Patient with past or current symptoms of HF associated with structural heart disease Patients with known structural heart disease and symptoms of dyspnea, fatigue, reduced exercise tolerance NYHA classes I, II, III, and IV
D Patient with refractory (end-stage) disease who requires specialized treatment strategies such as mechanical circulatory support, continuous inotropic infusions, cardiac transplantation, or hospice care Patients who have marked symptoms at rest despite maximal medical therapy NYHA class IV


  1. Aurigemma GP (2006). "heart failure--a common and lethal condition by any name". N Engl J Med. 355 (3): 308–10. doi:10.1056/NEJMe068128. PMID 16855273.
  2. Yancy CW, Jessup M, Bozkurt B, Masoudi FA, Butler J, McBride PE; et al. (2013). "2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. doi:10.1016/j.jacc.2013.05.019. PMID 23747642.
  3. Template:DorlandsDict
  4. Jessup. M, et al. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation. 2009 Apr 14;119(14):1977-2016. PMID 19324967