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Heart Failure Overview


What Are the Types of Heart Failure?

Systolic dysfunction (or systolic heart failure) occurs when the heart muscle doesn't contract with enough force, so there is less oxygen-rich blood that is pumped throughout the body.

Diastolic dysfunction (or diastolic heart failure) occurs when the heart contracts normally, but the ventricle -- the main pumping chamber -- does not relax properly, reducing the amount of blood that can enter the heart and raising blood pressure in the lungs.

A test called the ejection fraction (EF) is used measure how well your heart pumps with each beat to help determine if systolic or diastolic dysfunction is present. The ejection fraction is a measure of the percentage of blood that your heart pumps out with each beat. Your doctor can discuss which condition you have.

In patients with systolic heart failure, the ejection fraction is less than 40%. Imaging studies such as an echocardiogram (heart ultrasound) show the heart is enlarged and pumps out less than a normal amount of blood with each beat. 

In contrast, patients with diastolic heart failure usually have a normal ejection fraction and normal heart pumping capability, but an echocardiogram shows that the heart does not fill up with blood properly during the heart relaxation phase that occurs between beats.

Stages of Heart Failure

In 2001, the American Heart Association (AHA) and American College of Cardiology (ACC) developed the "Stages of Heart Failure." These stages, which were updated in 2005, will help you understand that heart failure is often a progressive condition and can worsen over time. They will also help you understand why a new medication was added to your treatment plan and may help you understand why lifestyle changes and other treatments are needed.

The stages classified by the AHA and ACC are different than the New York Heart Association (NYHA) clinical classifications of heart failure that rank patients as class I-II-III-IV, according to the degree of symptoms or functional limits. Ask your doctor what stage of heart failure you are in.

Check the table below to see if your therapy matches what the AHA and ACC recommend. Note that you cannot go backward in stage, only forward.

The table below outlines a basic plan of care that may or may not apply to you, based on the cause of your heart failure and your special needs. Ask your doctor to explain therapies that are listed if you do not understand why you are or are not receiving them.


Definition of Stage

Usual Treatments

Stage A

People at high risk of developing heart failure (pre-heart failure), including people with:
  • High blood pressure
  • Diabetes
  • Coronary artery disease
  • Metabolic syndrome
  • History of cardiotoxic drug therapy
  • History of alcohol abuse
  • History of rheumatic fever
  • Family history of cardiomyopathy
  • Exercise regularly.
  • Quit smoking.
  • Treat high blood pressure.
  • Treat lipid disorders.
  • Discontinue alcohol or illegal drug use.
  • An angiotensin converting enzyme inhibitor (ACE inhibitor) or an angiotensin II receptor blocker (ARB) is prescribed if you've had coronary artery disease or if you have diabetes, high blood pressure, or other vascular or cardiac conditions.
  • Beta-blockers may be prescribed if you have high blood pressure or if you've had a previous heart attack.

Stage B

People diagnosed with systolic left ventricular dysfunction but who have never had symptoms of heart failure, including people with:

  • Prior heart attack
  • Valve disease
  • Cardiomyopathy

The diagnosis is usually made when an ejection fraction of less than 40% is found during an echocardiogram test.

  • Treatment methods above for Stage A apply.
  • All patients should take an angiotensin converting enzyme inhibitor (ACE inhibitors) or angiotensin II receptor blocker (ARB).
  • Beta-blockers should be prescribed for patients after a heart attack.
  • An aldosterone inhibitor may be prescribed if the symptoms continue while on good doses of beta blockers and ACE/ARB medications.
  • Surgery options for coronary artery repair and valve repair or replacement (as appropriate) should be discussed.
  • If appropriate, surgery options should be discussed for patients who have had a heart attack.

Stage C

Patients with known systolic heart failure and current or prior symptoms. Most common symptoms include:

  • Shortness of breath
  • Fatigue
  • Reduced ability to exercise
  • Treatment methods above for Stage A apply.
  • All patients should take an angiotensin converting enzyme inhibitor (ACE inhibitors) and beta-blockers.
  • African-American patients may be prescribed a hydralazine/nitrate combination if symptoms persist.
  • Diuretics (water pills) and digoxin may be prescribed if symptoms persist.
  • An aldosterone inhibitor may be prescribed when symptoms remain severe with other therapies.
  • Restrict dietary sodium (salt)
  • Monitor weight
  • Restrict fluids (as appropriate)
  • Drugs that worsen the condition should be discontinued.
  • As appropriate, cardiac resynchronization therapy (biventricular pacemaker) may be recommended.
  • An implantable cardiac defibrillator (ICD) may be recommended.

Stage D

Patients with systolic heart failure and presence of advanced symptoms after receiving optimum medical care.

  • Treatment methods for Stages A, B ,& C apply.
  • Patient should be evaluated to determine if the following treatments are available options: heart transplant, ventricular assist devices, surgery options, research therapies, continuous infusion of intravenous inotropic drugs, and end-of-life (palliative or hospice) care.


WebMD Medical Reference

Reviewed by James Beckerman, MD, FACC on February 12, 2014
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