ACC/AHA heart failure stage
Measured Factor Disease
- Heart failure
- End-stage heart failure
Measured Factor Detail
The ACC/AHA heart failure stage describes the stages of heart failure and suggests appropriate therapy for each stage.
Stage N/A suggests no substantial risk for heart failure based on ACC/AHA staging guidelines.
Stage A describes high risk for heart failure without structural heart disease or symptoms of heart failure. Therapies for stage A target high blood pressure, lipid disorders, thyroid disorders, smoking cessation, use of Angiotensin Converting Enzyme (ACE) inhibitors in appropriate patients, regular exercise, alcohol/illicit drug avoidance, ventricular rate control in patients with supraventricular tachyarrhythmias, and periodic evaluation for signs and symptoms of heart failure.
Stage B describes structural heart disease without symptoms of heart failure. Therapies for stage B include measures in stage A and beta blockers, ACE inhibitors, valve replacement or repair in appropriate patients.
Stage C describes structural heart disease with past or present symptoms of heart failure. Therapies for stage C include measures in stage A and B and ACE inhibitors, diuretics, beta blockers, digitalis, salt restriction Withdrawal of nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking drugs is encouraged.
Stage D describes end-stage heart failure. Therapies for stage D include measures in stage A, B, and C and demands specialized treatment such as mechanical circulatory devices, heart transplantation, continuous IV inotropic infusions for palliation, or hospice care.
Measured Factor High Impact
- Stages A-D requires treatments that prevent or treat heart failure.
- Critical High: Stage D
- Normal: Stage N/A
- Normal Adult Male: Stage N/A
- Normal Adult Female: Stage N/A
- Normal Geriatric Male: Stage N/A
- Normal Geriatric Female: Stage N/A
Study Validation 1
This study reviewed and discussed therapy recommendations in the American College of Cardiology (ACC)/American Heart Association (AHA) 2005 guideline updates through clinical trials, observational studies, and review articles. The guidelines recommended therapies for stages A and B when patients do not yet have clinical heart failure but are clearly at risk, and for stages C and D for patients with symptomatic heart failure. The guidelines emphasized the important role of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, beta-adrenergic blockers, and aldosterone antagonists. The guidelines also addressed the roles of combination therapy and selective addition of hydralazine and isosorbide dinitrate. The study concluded that the guidelines provided evidence-based therapy recommendations that were further clarified by recent clinical trial findings.
Study Additional 1
Breast cancer treatments can cause heart failure in a subset of patients. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines classify patients receiving cardiotoxic medications as stage A, which is a high risk stage for developing heart failure. Neuregulin, a cardioprotective growth factor, usually declines in patients with stages C and D of heart failure. A prospective study looked at the risk of heart failure development in 78 women with breast cancer and receiving either anthracycline or trastuzumab. Patients were predominately white with stage II breast cancer and a median age of 50 years. Left ventricular ejection fraction (LVEF) and neuregulin levels were measured before chemotherapy, after completion of anthracycline therapy, and/or 3 months into trastuzumab therapy. A reduction greater than 10 absolute percentage points in LVEF was observed in 21.4% of patients, suggesting these patients were progressing from stage A to stage B or C of heart failure. A significant drop in neuregulin levels was observed in patients treated with anthracycline and/or trastuzumab (P < 0.001). Those with the greatest decline in LVEF had higher baseline neuregulin levels, suggesting that neuregulin might be a prognostic marker in early-stage hear failure.
Study Additional 2
This study focused on predicting left ventricular (LV) dysfunction in heart failure patients using a combination of neurohormones and clinical factors. Data from 125 patients with N-Terminal pro-B-type natriuretic peptide (NT-proBNP) <100 were used in two models that predicted LV dysfunction and differentiated stage B from stage A and no heart failure. Model 1 with clinical factors and neurohormones showed lower false negative rate than model 2, which included only NT-proBNP (8.2% versus 13.7%). The study demonstrated that the combination of clinical factors and neurohormones may differentiate stage B from stage A or no heart failure.
Study Additional 3
This study looked at the prevalence and predictors for leg edema in 274 patients at risk for heart failure but without structural heart disease or symptoms of heart failure (stage A). Among 33 patients (12.0%) seen with leg edema, 29 of them had leg edema involved only the ankle and foot. Compared with patients without leg edema, those with leg edema were older (74 ± 11 years vs 69 ± 12 years, P = 0.006), more likely to present with pulmonary crackles (52% vs 31%, P < 0.03), and more likely to have varicose veins (55% vs 15%, P < 0.001). Both leg edema and varicose veins were seen in 19 patients. Multivariate analysis showed that varicose veins were the only independent predictor of leg edema (odds ratio: 8.18, 95% confidence interval: 3.92-17.1, P < 0.001). The study concluded that leg edema may be evaluated in heart failure patients, even when patients are only at risk for heart failure.