Criteria

New York Heart Association (NYHA) classification[113]

This classification is symptom-based and has primarily been used as shorthand to describe functional limitations. HF symptoms may progress from one class to the next in a given patient, but can also follow the path in reverse; for example, a patient with NYHA class IV symptoms might have quick improvement to class III with diuretic therapy alone.

  • Class I: Mild. No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitations, or dyspnoea.

  • Class II: Mild. Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitations, or dyspnoea.

  • Class III: Moderate. Marked limitation of physical activity. Comfortable at rest, but gentle activity causes fatigue, palpitations, or dyspnoea.

  • Class IV: Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

Universal definition and classification of heart failure: stages of HF[1]

  • At risk for HF (stage A): includes patients without current or prior symptoms or signs of HF, structural cardiac changes, or elevated biomarkers of heart disease, but who are at risk for HF.

  • Pre-HF (stage B): includes patients without current or prior symptoms or signs of HF, but who have evidence of either structural heart disease, abnormal cardiac function, or elevated natriuretic peptide or cardiac troponin.

  • HF (stage C): includes patients with current or prior symptoms and/or signs of HF caused by a structural and/or functional cardiac abnormality.

  • Advanced HF (stage D): includes patients with severe symptoms and/or signs of HF at rest, recurrent hospitalisations despite guideline-directed medical therapy (GDMT), refractory or intolerant to GDMT, requiring advanced therapies such as consideration for transplantation, mechanical circulatory support, or palliative care.

American Heart Association/American College of Cardiology/Heart Failure Society of America stages of heart failure[7]

  • At risk for HF (stage A): includes patients who do not have current or prior symptoms or signs of HF, structural or functional cardiac changes, or abnormal biomarkers, but who are at risk for HF (e.g., hypertension, cardiovascular disease, obesity, family history or genetic variant for cardiomyopathy, exposure to cardiotoxic agents).

  • Pre-HF (stage B): includes patients who do not have current or prior symptoms or signs of HF, but who do have evidence of either structural heart disease; increased filling pressures; or risk factors with either elevated natriuretic peptide or cardiac troponin in the absence of competing diagnoses.

  • Symptomatic HF (stage C): includes patients with current or prior symptoms and/or signs of HF.

  • Advanced HF (stage D): includes patients with marked symptoms of HF that interfere with daily life and with recurrent hospitalisations despite attempts to optimise GDMT.

Framingham criteria for the diagnosis of congestive HF[33]

HF is essentially a clinical diagnosis. Clinical criteria for diagnosing HF, the Framingham criteria for the diagnosis of congestive HF, were established before the widespread use of echocardiographic assessment of systolic and diastolic dysfunction. The Framingham clinical criteria, listed below, have been extremely useful for identifying HF patients, both in clinical practice and in epidemiological studies, for more than 40 years. However, because their specificity is greater than their sensitivity, it is recognised that they probably miss mild cases of HF. In order to come up with a definite diagnosis of congestive HF, one needs to have either 2 major criteria or the combination of 1 major and 2 minor criteria.

Major criteria:

  • Neck vein distension

  • Rales

  • Acute pulmonary oedema

  • S3 gallop

  • Increased venous pressure greater than 16 cm of water

  • Circulation time greater than 25 seconds

  • Hepatojugular reflux

  • Cardiomegaly

  • Paroxysmal nocturnal dyspnoea or orthopnoea.

Minor criteria:

  • Ankle oedema

  • Night cough

  • Dyspnoea on exertion

  • Hepatomegaly

  • Pleural effusion

  • Less than one third maximum vital capacity

  • Tachycardia (heart rate >120 bpm).

Major or minor criteria:

  • Weight loss greater than 4.5 kg in 5 days in response to treatment.

Heart Failure Association of the European Society of Cardiology (HFA-ESC) 2018 criteria for the definition of advanced HF[8][114]

For a diagnosis of advanced HF, the following criteria must be present despite optimal medical treatment:

  • Severe and persistent symptoms of HF (NYHA class III or IV)

  • Severe cardiac dysfunction defined by left ventricular (LV) ejection fraction ≤30%, isolated right ventricular failure, non-operable severe valvular abnormalities, non-operable severe congenital abnormalities, or persistently high (or increasing) B-type natriuretic peptide (BNP) or N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels and severe diastolic dysfunction or LV structural abnormalities (according to the ESC definitions of HF with preserved ejection fraction [HFpEF] and HF with mildly reduced ejection fraction [HFmrEF])

  • Episodes of pulmonary or systemic congestion requiring high-dose intravenous diuretics or episodes of low output requiring inotropes or vasoactive drugs or malignant arrhythmias causing >1 unplanned hospitalisation in the last 12 months

  • Severe impairment of exercise capacity with inability to exercise or low 6-minute walk test (<300 m) or pVO₂ <12mL/kg/minute or <50% predicted value, estimated to be of cardiac origin.

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