Treatment and Stages

ACCF/AHA Stages of HF NYHA Functional Classification  
A High risk for HF but no structural heart disease or sx of HF None  
B Structural heart disease but no s/sx of HF I No limitation physical activity
Ordinary physical activity does not cause HF sx
C Structural heart disease with prior or current symptoms of HF
II Slight limitation of physical activity.

Ordinary physical activity causes HF sx

Comfortable at rest

III Marked limitation of physical activity.

Less than ordinary physical activity causes HF sx

Comfortable at rest

IV Unable to carry on any physical activity without HF sx

HF sx at rest


Stage A Control HTN and lipid disorders using current guidelines
Control or avoid contributing conditions (obesity, diabetes, smoking, cardiotoxic agents)
Consider ACEi when appropriate comorbidities (diabetes, HTN, etc.)


Stage B Non-Pharmacologic Implantable Cardioverter Defibrillator (ICD) placement
Revascularization or valvular surgery
Pharmacologic In pts with history of MI or acute coronary syndrome (ACS) and/or reduced EF to reduce morbidity/mortality

·       ACEi or ARB if ACEi intolerant

·       Evidence approved BB (metoprolol succinate, bisoprolol, carvedilol)

HARM Non-dihydropyridine calcium channel blockers due to negative inotropic effects



Stage C Non-Pharmacologic Educate patients on heart failure and relevant topics

·       Medication adherence

·       Lifestyle (physical activity, heart healthy/low sodium diet, etc.)

·       Monitoring (weight, symptoms)

Fluid restriction < 2 Liters / day (if severe edema – really more prevalent in Stage D)
Sodium Restriction < 1.5 grams / day
Cardiac Resynchronization Therapy (CRT)
Pharmacologic In patients with HFrEF and current or prior HF sx to reduce morbidity/mortality

·       ACEi or ARB if ACEi intolerant

·       Evidence approved BB

In HFrEF pts with current or prior sx AND one of the following: EF≤40% and recent MI or diabetes, EF≤35%, or NYHA II with hx of prior hospitalization or elevated BNP to decrease morbidity/mortality

·       Aldosterone Antagonist (AA)

In African American patients receiving optimal tx with ACEi/ARB and BB but still having sx to reduce morbidity/mortality

·       Hydralazine and Isosorbide Nitrate

In patients with HFrEF intolerant to ACEi/ARB to reduce morbidity/mortality

·       Hydralazine and Isosorbide Nitrate

In STABLE pts who tolerate max ACEi/ARB to further reduce morbidity/mortality

·       Switch to Angiotensin Receptor – Neprilysin Inhibitor (ARNi)

In patients with excess fluid retention to reduce symptoms (dyspnea/edema) & hospitalizations

·       Diuretics (Loops preferred, may use thiazide or K+ sparing)

In HFrEF pts to reduce hospitalizations

·       Digoxin

·       Ivabradine (in stable, symptomatic pts at max dose BB, in sinus rhythm, and HR>70bpm)

·       Omega-3 – provides pay provide minor reduction in mortality and CV hospitalizations in HFrEF and HFpEF but may also increase bleed risk

·       Statins –only in patients already indicated for statins (prevents symptomatic HF and CV events)

·       Anti-coagulants – only if patient has comorbid Atrial Fibrillation (prevents CV events)

HARM Avoid any drugs known to exacerbate heart failure (ex: antiarrhythmic drugs, most CCB (except amlodipine), NSAIDS, or thiazolidinedione)


Stage D Non-Pharmacologic
Mechanical Circulatory Support
Left Ventricular Assist Device (LVAD)
Cardiac Transplant
Coronary revascularization – Coronary artery bypass grafting (CABG) or percutaneous intervention (PCI)
Pharmacologic In hospitalized patients with acute decompensated HF

·    IV Diuretics (usually Loops)

In patients with decompensated heart failure as adjuvant to diuretics for relief of dyspnea

·       Nitrates (Nitroprusside, nitroglycerin)

·       Nesiritide

For short term in patients refractory to other treatments or pts waiting for revascularization, mechanical circularly support (MCS), heart transplant, and needing to maintain systemic perfusion OR for patients in palliative care

·       IV positive Inotropic therapy (dobutamine, milrinone, dopamine)

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