Signs and symptoms

Signs and symptoms of heart failure include the following:

 Exertional dyspnea and/or dyspnea at rest
 Orthopnea
 Acute pulmonary edema
 Chest pain/pressure and palpitations
 Tachycardia
 Fatigue and weakness
 Nocturia and oliguria
 Anorexia, weight loss, nausea
 Exophthalmos and/or visible pulsation of eyes
 Distention of neck veins
 Weak, rapid, and thready pulse
 Rales, wheezing
 S 3 gallop and/or pulsus alternans
 Increased intensity of P 2 heart sound
 Hepatojugular reflux
 Ascites, hepatomegaly, and/or anasarca
 Central or peripheral cyanosis, pallor

Diagnosis
Heart failure criteria, classification, and staging
The Framingham criteria for the diagnosis of heart failure consists of the concurrent
presence of either two major criteria or one major and two minor criteria. [1]
Major criteria comprise the following:
 Paroxysmal nocturnal dyspnea
 Weight loss of 4.5 kg in 5 days in response to treatment
 Neck vein distention
 Rales
 Acute pulmonary edema
 Hepatojugular reflux
 S 3 gallop
 Central venous pressure greater than 16 cm water
 Circulation time of 25 seconds or longer
 Radiographic cardiomegaly
 Pulmonary edema, visceral congestion, or cardiomegaly at autopsy
Minor criteria (accepted only if they cannot be attributed to another medical condition)
are as follows:
 Nocturnal cough
 Dyspnea on ordinary exertion
  A decrease in vital capacity by one third the maximal value recorded
 Pleural effusion
 Tachycardia (rate of 120 bpm)
 Hepatomegaly
 Bilateral ankle edema
The New York Heart Association (NYHA) classification system categorizes heart failure
on a scale of I to IV, [2]  as follows:
 Class I: No limitation of physical activity
 Class II: Slight limitation of physical activity
 Class III: Marked limitation of physical activity
 Class IV: Symptoms occur even at rest; discomfort with any physical activity
The American College of Cardiology/American Heart Association (ACC/AHA) staging
system is defined by the following four stages [3] :
 Stage A: High risk of heart failure but no structural heart disease or symptoms of
heart failure
 Stage B: Structural heart disease but no symptoms of heart failure
 Stage C: Structural heart disease and symptoms of heart failure
 Stage D: Refractory heart failure requiring specialized interventions
Testing
The following tests may be useful in the initial evaluation for suspected heart
failure [3, 4, 5] :
 Complete blood count (CBC)
 Iron studies
 Urinalysis
 Electrolyte levels
 Renal and liver function studies
 Fasting blood glucose levels
 Lipid profile
 Thyroid stimulating hormone (TSH) levels
 B-type natriuretic peptide levels
 N-terminal pro-B-type natriuretic peptide levels
 Electrocardiography
 Chest radiography
 Two-dimensional (2-D) echocardiography
 Nuclear imaging [6]
 Maximal exercise testing
 Pulse oximetry or arterial blood gas

Heart Failure Criteria, Classification, and Staging

Framingham system for diagnosis of heart failure
In the Framingham system, the diagnosis of heart failure requires that either
two major criteria or one major and two minor criteria be present concurrently,
as shown in Table 1 below. [1] Minor criteria are accepted only if they cannot be
attributed to another medical condition.

Major Criteria Minor Criteria

Paroxysmal nocturnal dyspnea Nocturnal cough

Weight loss of 4.5 kg in 5 days

Dyspnea on ordinary exertion
in response to treatment

A decrease in vital capacity by

Neck vein distention one third the maximal value
recorded

Rales Pleural effusion

Acute pulmonary edema Tachycardia (rate of 120 bpm)

Hepatojugular reflux Hepatomegaly

S3 gallop Bilateral ankle edema

Central venous pressure >16

 
cm water

Circulation time of ≥25 seconds  

Radiographic cardiomegaly  

Pulmonary edema, visceral

congestion, or cardiomegaly at  
autopsy
Source:  Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of
heart failure: the Framingham Study. J Am Coll Cardiol. 1993
Oct;22(4 suppl A):6A-13A. [1]

ACC/AHA stages of heart failure

The American College of Cardiology/American Heart Association (ACC/AHA) developed
a classification that described the development and progression of heart failure and that
"recognizes that there are established risk factors and structural prerequisites for the
development of [heart failure] and that therapeutic interventions introduced even before
the appearance of [left ventricular] dysfunction or symptoms can reduce the population
morbidity and mortality of [heart failure]."  [3] Table 3, below, summarizes the
development of heart failure.
Table 3. ACC/AHA Stages of Heart Failure Development (Open Table in a new window)

Leve
Description Examples Notes
l

Patients with
coronary artery
At high risk for disease,
heart failure but hypertension, or
without structural diabetes mellitus
A  Patients with
heart disease or without impaired
symptoms of LV function, LVH, predisposing risk
heart failure or geometric factors for
chamber developing heart
distortion failure
 Corresponds with
patients with NYHA
Patients who are class I heart failure
Structural heart
asymptomatic
disease but
but who have
B without
LVH and/or
signs/symptoms
impaired LV
of heart failure
function

C Structural heart Patients with  The majority of

disease with known structural patients with heart
current or past heart disease failure are in this
symptoms of and shortness of stage
heart failure breath and
  Corresponds with
fatigue, reduced
patients with NYHA
exercise
class I-IV heart
tolerance
failure

 Patients in this
stage may be
eligible to receive
mechanical
circulatory support,
receive continuous
Patients who
Refractory heart inotropic infusions,
have marked
failure requiring undergo procedures
D symptoms at rest
specialized to facilitate fluid
despite maximal
interventions removal, or undergo
medical therapy
heart
transplantation or
other procedures
 Corresponds with
patients with NYHA
class IV heart failure

LV = left ventricle; LVH = LV hypertrophy; NYHA = New York Heart Association.

 
Source: Yancy CW, Jessup M, Bozkurt B, et al, for the American College of
Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a
report of the American College of Cardiology Foundation/American Heart
Association Task Force on Practice Guidelines. Circulation. 2013 Oct
15;128(16):e240-327. [3]

NYHA classification of functional heart failure

The New York Heart Association (NYHA) functional classification of heart failure is
based on the patient's symptom severity and the amount of exertion that is needed to
provoke their symptoms. See Table 2 below.
Table 2. NYHA Functional Classification of Heart Failure (Open Table in a new window)
Cla
Functional Capacity
ss

I Patients without limitation of physical activity

Patients with slight limitation of physical activity, in which

II ordinary physical activity leads to fatigue, palpitation,
dyspnea, or anginal pain; they are comfortable at rest

Patients with marked limitation of physical activity, in which

III less than ordinary activity results in fatigue, palpitation,
dyspnea, or anginal pain; they are comfortable at rest

Patients who are not only unable to carry on any physical

activity without discomfort but who also have symptoms of
IV heart failure or the anginal syndrome even at rest; the
patient's discomfort increases if any physical activity is
undertaken

Source:  American Heart Association. Classes of heart failure.

Available
at: http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutH
eartFailure/Classes-of-Heart-
Failure_UCM_306328_Article.jsp#.WUcGf-vyuHs. Accessed: June
18, 2017.
ACC/AHA Staging
Stage A
American College of Cardiology/American Heart Association (ACC/AHA) stage A
patients are at high risk for heart failure but do not have structural heart disease or
symptoms of heart failure. Thus, management in these cases focuses on prevention,
through reduction of risk factors. Measures include the following  [3] :
 Treat hypertension (optimal blood pressure: < 130/80 mm Hg [56] )
 Encourage smoking cessation
 Treat lipid disorders
 Encourage regular exercise
 Discourage alcohol intake and illicit drug use
Patients who have a family history of dilated cardiomyopathy should be screened with a
comprehensive history and physical examination together with echocardiography and
transthoracic echocardiography every 2-5 years.  [4]
Stage B
ACC/AHA stage B patients are asymptomatic, with left ventricular (LV) dysfunction from
previous myocardial infarction (MI), LV remodeling from LV hypertrophy (LVH), and
asymptomatic valvular dysfunction, which includes patients with New York Heart
Association (NYHA) class I heart failure (see Heart Failure Criteria, Classification, and
Staging for a description of NYHA classes).  [3] In addition to the heart failure education
and aggressive risk factor modification used for stage A, treatment with an angiotensin-
converting enzyme inhibitor/angiotensin-receptor blocker (ACEI/ARB) and/or beta-
blockade is indicated.
Evaluation for coronary revascularization either percutaneously or surgically, as well as
correction of valvular abnormalities, may be indicated.  [3] Treatment with an implantable
cardioverter-defibrillator (ICD) for primary prevention of sudden death in patients with an
LV ejection fraction (LVEF) below 30% that is more than 40 days post-MI is reasonable
if the expected survival is more than 1 year.
There is less evidence for implantation of an ICD in patients with nonischemic
cardiomyopathy, an LVEF less than 30%, and no heart failure symptoms. There is no
evidence for use of digoxin in these populations.  [57] Aldosterone receptor blockade with
eplerenone is indicated for post-MI LV dysfunction.
Stage C
ACC/AHA stage C patients have structural heart disease and current or previous
symptoms of heart failure; ACC/AHA stage C corresponds with NYHA class I-IV heart
failure. The preventive measures used for stage A disease are indicated, as is dietary
sodium restriction.
Drugs routinely used in these patients include ACEI/ARBs, beta-blockers, or
angiotensin receptor–neprilysin inhibitors (ARNIs), in conjunction with evidence-based
beta-blockers, and loop diuretics for fluid retention.  [3, 56, 58] For selected patients,
therapeutic measures include aldosterone receptor blockers, hydralazine and nitrates in
combination, and cardiac resynchronization with or without an ICD
(see Electrophysiologic Intervention). [3, 56, 58]
A meta-analysis performed by Badve et al suggested that the survival benefit of
treatment with beta-blockers extends to patients with chronic kidney disease and
systolic heart failure (risk ratio 0.72). [59]

The 2016 and 2017 ACC/AHA focused updates to the 2013 guidelines added a class IIa
recommendation for ivabradine, a sinoatrial node modulator, in patients with stage C
heart failure. [56, 58]  They indicate that ivabradine may reduce hospitalization for patients
with symptomatic (NYHA class II-III) stable chronic heart failure with reduced ejection
fraction (LVEF ≤35%) who are receiving recommended therapy, including a beta
blocker at the maximum tolerated dose, and who are in sinus rhythm with a heart rate of
70 bpm or greater at rest. [56, 58]
Stage D
ACC/AHA stage D patients have refractory heart failure (NYHA class IV) that requires
specialized interventions. Therapy includes all the measures used in stages A, B, and
C. Treatment considerations include heart transplantation or placement of an LV assist
device in eligible patients; pulmonary catheterization; and options for end-of-life
care. [3] For palliation of symptoms, continuous intravenous infusion of a positive inotrope
may be considered.