What Is Heart Failure?

Heart failure — also known as congestive heart failure — is a cardiovascular condition in which your heart isn’t pumping blood as well as it should. The heart doesn’t stop working. Instead, it has trouble pumping blood or filling with enough blood between beats.

The 4 Stages of Heart Failure

The American College of Cardiology (ACC) and American Heart Association (AHA) developed a system that divides heart failure into four stages — from A to D — to describe how the condition progresses over time. You may stay in a stage for years or progress to a later stage.

Stage A: At Risk for Heart Failure

People in stage A have not yet been diagnosed with heart failure but have a high risk of developing this condition. People don’t have any symptoms of heart failure or known structural problems with the heart at this stage.

Factors that can increase your risk of heart failure include:

• Other cardiovascular conditions — Hypertension and CAD
• Metabolic disorders — Type 2 diabetes and obesity
• Cardiotoxic agents — Certain medications that can cause heart failure
• Family history — A family member with cardiomyopathy

Manage these conditions with prescription medications and your doctor’s guidance. Regular screenings can detect hypertension, high cholesterol, and type 2 diabetes early.

Stage A doesn’t mean you will develop heart failure. Many people with risk factors who take steps to manage their risks may never progress to later stages. Stage A is not a heart failure diagnosis, but it’s a good time to learn the warning signs.

Stage B: Pre-Heart Failure

People in stage B heart failure don’t have symptoms of heart failure, but testing shows changes in their heart that can cause symptoms later. People are often unaware they’re in stage B unless these changes are discovered by their doctor.

An echocardiogram (ECHO) — a test that uses sound waves to create pictures of the heart — may show a problem in the way the left ventricle pumps blood to the rest of the body or signs of heart muscle stiffness. Blood tests may also show signs of stress or injury to the heart.

Stage B can increase the risk of having symptoms of heart failure in the future. Managing risk factors and early treatment may help lower that risk.

Stage C: Symptomatic Heart Failure

People in stage C have structural changes in the heart and current or previous symptoms of heart failure. Doctors may use the New York Heart Association (NYHA) classes to understand how much your symptoms affect your daily activities.

The NYHA system places people with stage C or stage D heart failure in one of four classes based on their physical activity level and heart failure symptoms:

• Class 1 — No limitation during usual physical activity
• Class 2 — Mild limitations, with symptoms during usual physical activity
• Class 3 — Marked limitations, with symptoms during lighter-than-usual activity
• Class 4 — Symptoms even at rest

You may also see these classes written with Roman numerals (Class I, Class II, Class III, and Class IV).

Your doctor will assign your heart failure class at diagnosis and monitor your progression with treatment. Stage C can progress to stage D, but progression is not inevitable. Treatment can help slow progression, manage symptoms, and improve quality of life.

Stage D: Advanced Heart Failure

People in stage D have severe heart failure symptoms that are hard to manage or control even with treatment. These symptoms usually affect daily activities and lead to hospitalizations.

At this stage, treatments are intended to give a person the best possible quality of life for as long as possible. Depending on the person’s health and goals, advanced treatment options may include:

• Referral to a heart failure specialist team
• Surgery to implant a device that helps your heart stay in the right rhythm (pacemaker or defibrillator) or pump blood more effectively (left ventricular assist device, or LVAD)
• Heart transplant
• Palliative or hospice care

The outlook for stage D heart failure depends on many factors, such as the person’s overall health, other medical conditions, and response to treatment.

• Angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) — These medications lower blood pressure and reduce strain on the heart.
• Angiotensin receptor-neprilysin inhibitor (ARNI) — This medication reduces strain on the heart and helps the body get rid of extra salt and fluid. It is used instead of an ACE inhibitor or ARB.
• Beta-blockers — These medications slow the heart rate and reduce how hard the heart has to work.
• Aldosterone antagonists — These medications help lower blood pressure and reduce salt and fluid retention.
• Sodium-glucose cotransporter-2 (SGLT2) inhibitors — These medications lower blood sugar and may also lower body weight and blood pressure. They can reduce heart failure hospitalizations in people with HFrEF, HFmrEF, or HFpEF.

• Soluble guanylate cyclase (sGC) stimulators — These medications help relax and widen blood vessels.
• Diuretics — Also known as water pills, these medications can help control edema.
• Ivabradine (Corlanor) — This medication slows down the heart rate without lowering blood pressure.
• Digoxin (Lanoxin) — This medication can strengthen the heart’s pumping action and slow a heart rate that is too fast.