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    ACC/AHA Heart Failure Staging

    Describes stages of heart failure and provides recommendations for therapy by stage.
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    When to Use
    Pearls/Pitfalls
    Why Use
    • Patients with known heart failure.
    • Patients at risk for heart failure.
    • Developed jointly by the American College of Cardiology (ACC) and American Heart Association (AHA) to complement, but not replace, the more widely-used New York Heart Association (NYHA) functional classification.
    • Based on expert consensus.
    • Matches stage to treatment options, unlike other classification systems.
    • Other heart failure classification systems include Forrester Class and NYHA Class.
    • Unlike other classification systems, the ACC/AHA stages include patients at risk for heart failure and corresponding management options.

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    Consider treatment based on stage.

    Formula

    • Stage A: High risk for developing HF but no structural disorder of the heart
    • Stage B: Structural disorder of the heart but has never developed symptoms of HF
    • Stage C: Past or current symptoms of HF associated with underlying structural heart disease
    • Stage D: End-stage disease requiring specialized treatment strategies such as mechanical circulatory support, continuous inotropic infusions, cardiac transplantation, or hospice care

    Facts & Figures

    Stage Class I recommendations*
    A
    1. Control of systolic and diastolic hypertension in accordance with recommended guidelines. (Level of Evidence: A)
    2. Treatment of lipid disorders in accordance with recommended guidelines. (Level of Evidence: B)
    3. Avoidance of patient behaviors that may increase the risk of HF (e.g., smoking, alcohol consumption, and illicit drug use). (Level of Evidence: C)
    4. Angiotensin converting enzyme (ACE) inhibition in patients with a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension and associated cardiovascular risk factors. (Level of Evidence: B)
    5. Control of ventricular rate in patients with supraventricular tachyarrhythmias. (Level of Evidence: B)
    6. Treatment of thyroid disorders. (Level of Evidence: C)
    7. Periodic evaluation for signs and symptoms of HF. (Level of Evidence: C)
    B
    1. ACE inhibition in patients with a recent or remote history of myocardial infarction regardless of ejection fraction. (Level of Evidence: A)
    2. ACE inhibition in patients with a reduced ejection fraction, whether or not they have experienced a myocardial infarction. (Level of Evidence: B)
    3. Beta-blockade in patients with a recent myocardial infarction regardless of ejection fraction. (Level of Evidence: A)
    4. Beta-blockade in patients with a reduced ejection fraction, whether or not they have experienced a myocardial infarction. (Level of Evidence: B)
    5. Valve replacement or repair for patients with hemodynamically significant valvular stenosis or regurgitation. (Level of Evidence: B)
    6. Regular evaluation for signs and symptoms of HF. (Level of Evidence: C)
    7. Measures listed as class I recommendations for patients in stage A. (Levels of Evidence: A, B, and C as appropriate).
    C
    1. Diuretics in patients who have evidence of fluid retention. (Level of Evidence: A)
    2. ACE inhibition in all patients unless contraindicated. (Level of Evidence: A)
    3. Beta-adrenergic blockade in all stable patients unless contraindicated. Patients should have no or minimal evidence of fluid retention and should not have required treatment recently with an intravenous positive inotropic agent. (Level of Evidence: A)
    4. Digitalis for the treatment of symptoms of HF, unless contraindicated. (Level of Evidence: A)
    5. Withdrawal of drugs known to adversely affect the clinical status of patients (e.g., nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking drugs). (Level of Evidence: B)
    6. Measures listed as class I recommendations for patients in stages A and B (Levels of Evidence: A, B, and C as appropriate).
    D
    1. Meticulous identification and control of fluid retention. (Level of Evidence: B)
    2. Referral for cardiac transplantation in eligible patients. (Level of Evidence: B)
    3. Referral to an HF program with expertise in the management of refractory HF. (Level of Evidence: A)
    4. Measures listed as class I recommendations for patients in stages A, B, and C. (Levels of Evidence: A, B, and C as appropriate).

    From Hunt et al, 2001.

    *Conditions for which there is evidence and/or general agreement that a given procedure/therapy is useful and effective. For full recommendations, see Hunt et al, 2001.

    Evidence Appraisal

    The ACC/AHA Heart Failure Stages were developed jointly by the American College of Cardiology (ACC) and American Heart Association (AHA) by expert consensus. They were intended to complement, but not replace, the more widely-used New York Heart Association (NYHA) functional classification, since contemporary treatment recommendations did not vary by class.

    Dr. Sharon Hunt

    About the Creator

    Sharon Hunt, MD, is a professor of medicine at Stanford University as well as the Med Center Line. She is a member of the Cardiovascular Institute. Dr. Hunt's research focuses on cardiovascular diseases including heart failure and myocardial infarction and is a co-author on many ACC/AHA guidelines.

    To view Dr. Sharon Hunt's publications, visit PubMed