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How Does Heart Failure Progress Over Time?

Posted on September 08, 2022
Article written by
Emery Haley, Ph.D.

  • Heart failure can be divided into four stages of severity, based on heart function.
  • The symptoms you experience, your treatments, and your life expectancy will depend on your stage.
  • No matter what stage you are in, heart failure is a chronic health condition that can be managed with medical treatments and lifestyle changes.

Heart failure is a serious but manageable chronic condition in which the heart can’t pump blood efficiently. Heart failure often progresses over time, even with treatment. However, you can take steps to improve your quality of life when living with heart failure.

Members of MyHeartDiseaseTeam have discussed living with heart failure. One member wrote, “I have good days and bad days … I have a question for everyone: Does heart failure always progress? Will it get worse? Since I am in the beginning stages and am being treated, does that mean I will not progress to the next stage?”

The American College of Cardiology and American Heart Association developed a system that divides heart failure into four stages, from A to D, based on heart function — the higher the letter, the more severe the condition. Over time, you may progress from having normal heart function and heart failure risk (stage A) to experiencing severe changes in heart function (stage D). You only go forward through these stages, but you can remain at any stage for many years.

Stage A: Pre-Heart Failure

People in stage A have not yet been diagnosed with heart failure but have a high risk of developing this condition.

Risk Factors

Your risk of developing heart failure is based on a family history of cardiomyopathy (heart disease) and your other medical conditions. Medical conditions that increase your risk of heart failure include:

  • Other heart diseases such as arrhythmias (abnormal heart rhythms), high blood pressure, and coronary artery disease (CAD), including high cholesterol and atherosclerosis (buildup of fats and cholesterol within the blood vessels)
  • Metabolic disorders, including metabolic syndrome, diabetes, and obesity
  • HIV and AIDS
  • Viral infections including COVID-19
  • Thyroid and kidney disease
  • Sleep apnea (a condition in which your breathing stops and starts while you sleep)
  • Anemia (low levels of red blood cells)
  • Asthma or other chronic lung diseases

If you have any of these conditions, take your prescribed medications and follow your doctor’s instructions to keep symptoms under control. You should also get regular screenings to check for high blood pressure, high cholesterol, and type 2 diabetes. Some medications, such as certain cancer drugs, also can damage the heart.

Lifestyle Changes To Lower Risk

Smoking and heavy use of alcohol or drugs can increase your risk of heart failure, so get support to help you manage alcohol consumption or to quit smoking or use of other drugs.

Incorporate regular physical activity into your daily routine. The American Heart Association advises logging a weekly total of at least 150 minutes of moderate aerobic exercise (like walking at a brisk pace) or 75 minutes of vigorous aerobic activity (like running). Additionally, aim for two strength-training sessions that involve lifting weights or performing body-weight exercises.

Don’t worry if you can’t meet these goals immediately. Start with what you feel comfortable doing, and slowly increase your exercise.

You can also take charge of your heart failure risk by:

  • Managing your stress
  • Getting at least seven to nine hours of quality sleep every night
  • Eating a heart-healthy diet
  • Maintaining a healthy weight

Life Expectancy

If you are taking steps to keep your disease from getting worse, stage A pre-heart failure does not change your life expectancy compared with the general population. Many people with increased risk of heart failure never go past this stage.

Stage B: Silent or Structural Heart Failure

People in stage B heart failure have changes in their heart function but don’t yet experience symptoms of heart failure.

Signs

People are often unaware they are in stage B unless changes in their heart function are discovered by their doctor. Many people in stage B heart failure have an ejection fraction (EF) below 40 percent. EF is measured by an echocardiogram and describes how much blood your heart pumps out with each heartbeat. Other common changes to the heart that may be discovered by your doctor are:

  • Changes in the left ventricle (the heart’s most important part for pumping oxygenated blood to the rest of the body) that may occur silently as a result of your genes or prolonged high blood pressure
  • Damage from conditions like myocarditis (inflammation of the heart muscle), exposure to toxic chemicals, medications, or a heart attack
  • Faulty valves (problems with the heart’s four gatelike flaps that keep blood flowing in the right direction)

Treatments

Treatments for stage B heart failure aim to treat the underlying conditions affecting heart function and keep people symptom-free. Typical therapies for stage B heart failure include:

  • Decreasing exposure to toxins or medications that affect the heart — This might apply to excess alcohol or certain anticancer drugs.
  • ACE inhibitors or angiotensin 2 receptor blockers (ARBs) — These drugs may be useful if you have CAD, diabetes, or high blood pressure.
  • Beta-blockers — Your doctor may recommend these medications if you have high blood pressure or if you’ve had a heart attack and your EF is 40 percent or lower.
  • Surgery — A surgical procedure might be needed in certain cases, such as a coronary artery blockage or heart attack.
  • Soluble guanylate cyclase (sGC) stimulators — These medications increase the production of a chemical that relaxes and opens blood vessels. Vericiguat (Verquvo), a sGC stimulator that was approved by the US Food and Drug Administration (FDA) in 2021, was found to reduce hospitalizations in people with heart failure and an EF of less than 40 percent.

Life Expectancy

If you are taking steps to manage your risk of disease progression, stage B silent heart failure does not change your life expectancy, compared with the general population.

Stage C: Diagnosed Heart Failure

People in stage C have been diagnosed with heart failure and experience symptoms.

Signs and Symptoms

Common symptoms of stage C heart failure depend on your type of heart failure. People with left-sided heart failure typically experience:

  • Shortness of breath or cough
  • Rapid “pounding” or irregular heartbeats (palpitations)
  • Fatigue
  • Faintly blue fingertips or lips
  • Weak or unsteady legs
  • Trouble sleeping when lying flat
  • Sleepiness or trouble concentrating during the day

People with right-sided heart failure typically experience:

  • Swelling in the feet, ankles, legs, and abdomen caused by fluid buildup (edema)
  • Need to urinate during the night
  • Weight gain
  • Abdominal pain, nausea, or loss of appetite

An individual with heart failure could experience any combination of these symptoms, some of which may be caused by conditions other than heart failure.

Treatments

Treatments for stage C heart failure aim to control symptoms and stop heart failure from progressing to stage D. People in stage C should continue the lifestyle changes from stage A and treatments from stage B based on what their doctor recommends.

Additional treatments for stage C heart failure include:

  • Aldosterone antagonists — This type of medication may help if ACE inhibitors, ARBs, and beta-blockers don’t relieve your symptoms.
  • Diuretics — Also known as water pills, these medications can help control edema.
  • Fluid restriction — Limiting liquids to six to nine cups per day, depending on the severity of your symptoms, may be helpful if edema isn’t controlled by medication.
  • Hydralazine/nitroglycerin — This drug combination may help if other treatments don’t stop your symptoms.
  • Sodium-glucose cotransporter-2 inhibitors — Initially developed to treat diabetes, these medications may be beneficial in preventing heart failure.
  • Digitalis glycosides — The agents may help prevent hospital readmissions for certain people.

Even if treatments for stage C heart failure cause your symptoms to improve or stop, you still need to follow your regimen to slow further disease progression.

Life Expectancy

Although heart failure lowers life expectancy, you can still live for several years with stage C heart failure if you manage your condition with treatment. Specifically, one study found that 75 percent of people with stage C heart failure survived at least five years past their diagnosis.

Stage D: Advanced Heart Failure

People in stage D don’t respond to standard treatments (described above for earlier stages) and may experience symptoms, even while resting.

Signs and Symptoms

A person in stage D heart failure can experience any of the symptoms described in stage C, but the symptoms will be more severe and persistent.

Treatments

At this stage, treatments are intended to give a person the best possible quality of life for as long as possible. You should speak with your health care team to decide on your priorities for treatment. Options for advanced heart failure include:

Life Expectancy

Stage D heart failure significantly reduces your life expectancy. The average life expectancy for people with stage D heart failure is less than five years, but there is still hope — 20 percent of people in this stage survive more than five years, according to a study published in the journal Circulation.

Communicate With Your Health Care Team

Always speak with your cardiologist about any worsening symptoms, and discuss all your concerns, questions, and treatment options. Heart disease is a serious condition, but it can be managed with medical treatment and lifestyle changes.

Talk With Others Who Understand

On MyHeartDiseaseTeam, a social network for people with heart disease and their loved ones, over 52,000 members come together to ask questions, give advice, and share their stories with others who understand life with heart disease.

Are you living with progressing chronic heart failure? What has your experience been like, and do you have any tips for others with heart failure? Share your experience in the comments below, or start a conversation by posting on your Activities page.

All updates must be accompanied by text or a picture.
Larry A. Weinrauch, MD, FACC, FACP, FAHA is an assistant professor of medicine at Harvard Medical School with a focus on cardiovascular disease and clinical outcomes research. Review provided by VeriMed Healthcare Network. Learn more about him here.
Emery Haley, Ph.D. is a nonbinary science communicator with a passion for diversity, equity, and inclusion in STEM. Learn more about them here.

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