Importance of Prognostic and Functional Classification of Heart Failure

Tuesday, 13 July 2010

Ponrathi R. Athilingam, PhD, RN, ACNP
School of Nursing, University of Rochester, Rochester, NY

Learning Objective 1: Describe the American Heart Association staging and New York Heart Association classification of heart failure.

Learning Objective 2: Understand the evidence in assessing heart failure stages and classifications to map prevention and management of heart failure.

Heart failure (HF) is a group of signs and symptoms caused by many disease processes that have weakened the heart over time.  Although, HF course may be improved with modern therapies, it involves gradual deterioration with interrupted bouts of severe decompensation and ultimately death.
The American Heart Association (AHA)/American College of Cardiology (ACC) staging highlight the importance of known risk factors and structural abnormalities of the heart in the development of HF. It reinforces the concept that HF is a progressive disease whose onset can be prevented, or its progression halted by early identification and intervention. The New York Heart Association (NYHA) functional classification relates to symptoms of everyday activities and the patient's quality of life. Symptoms are graded at four levels based on how much they limit functional capacity.  Unlike the AHA/ACC staging system, the NYHA class often can shift from one level to another as functional capacity improves or worsens.
Table Comparing AHA/ACC stage and NYHA Classification
HF Stage
Structural Damage to Heart
NYHA Classification
Physical activity
High risk, no damage
Class I
No limitation
Damage, no or mild symptoms
Class II
Slight limitation
Damage amenable to treatment
Class III
Marked limitation
Damage, refractory to conventional treatment
Class IV
Unable to carry out any activity without discomfort.
Typical stage D patients include those who require frequent hospital admissions for HF, awaiting a heart transplant, supported with intravenous inotropes or mechanical assist devices, and are receiving hospice care for end-stage HF
Evidence suggests knowledge of assessing the AHA/ACC stages helps to prevent and manage HF in those at risk and complements NYHA classification system, which gauges the severity of symptoms in people who are at AHA/ACC stage C and D that augments timely dialogue regarding end life issues with end stage HF patients.