The 4 Stages of Congestive Heart Failure (A, B, C, and D) and What They Mean (2024)

Congestive heart failure (CHF) is a condition in which the heart isn't able to effectively pump blood to the body, leading to symptoms like shortness of breath, swelling, and fatigue. The American College of Cardiology/American Heart Association (ACC/AHA) uses a staging system for CHF, known as ACC/AHA staging.

Within this system are stages A through D, with A being at risk for heart failure and having no symptoms and D being advanced heart failure. As heart failure progresses from one stage to the next, life expectancy decreases.

This article will discuss the four stages of heart failure, its treatment, and prognosis.

Congestive Heart FailureThe 4 Stages of Congestive Heart Failure (A, B, C, and D) and What They Mean (1)

Stage A: At Risk for Congestive Heart Failure

In stage A heart failure, there are no symptoms or identified problems with the heart, but there are risk factors for heart failure. Some risk factors are out of a person's control, like genetics or family history of heart failure. Some risk factors that may be modified include:

  • High blood pressure
  • Diabetes
  • Coronary artery disease
  • Having obesity

In addition, exposure to some medications or toxic substances place you at higher risk for heart failure. This includes things like radiation and certain chemotherapy agents used for cancer treatment, as well as alcohol and drugs like cocaine or methamphetamines.

Progression and Life Expectancy

Stage A heart failure, meaning a person is at risk that can progress to later stages, is very common since risk factors are prevalent. For example, high blood pressure affects nearly half of the U.S. population.

One study that followed 413 patients with stage A heart failure over four years found that 35% progressed to stages B or C heart failure in that time frame.

Life expectancy with stage A heart failure varies greatly depending on age, overall health, and other underlying conditions. Survival rates aren't typically reported for stage A heart failure, but an older study, from 2007, did find a 97% five-year survival for people with stage A heart failure.

Treatment

Management of stage A heart failure involves aggressive lifestyle modifications, such as blood pressure, blood sugar, and cholesterol control, as well as eating a heart-healthy diet, getting regular physical activity, and avoiding smoking or drinking alcohol in excess.

Stage B: Pre-Heart Failure

In stage B heart failure, also known as pre–heart failure, there are abnormalities in the heart, but they are not yet significant enough to cause symptoms. There is evidence of structural or functional abnormalities in the heart, such as:

  • Valve problems
  • Thickening of the heart wall
  • Problem with the heart filling (diastolic dysfunction)
  • Reduced pumping function, as measured by the ejection fraction (reduced ejection fraction, also called systolic heart failure, is when the heart muscle does not contract effectively and can’t carry enough oxygen-rich blood throughout the body)
  • Elevated cardiac biomarkers, such as B-type natriuretic peptide (BNP)

Progression and Life Expectancy of Stage B Heart Failure

Over time, stage B heart failure can progress to symptomatic heart failure (stages C and D). In a study of preclinical heart failure involving 413 people with stage B heart failure, 6% progressed to symptomatic heart failure over four years.

A 2007 study found a 95.7% five-year survival rate for stage B heart failure. However, progression and survival are worse when looking at a specific subset of stage B heart failure. People with reduced ejection fraction are more likely to progress to symptomatic heart failure and had worse survival rates.

Treatment of Stage B Heart Failure

Treatment of stage B heart failure, as with stage A, includes aggressive risk factor modifications. In addition, certain medications may be beneficial in people with stage B heart failure, such as those with reduced ejection fraction or those with a history of heart attack. Depending on the individual, these may include:

  • Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)
  • Beta-blockers
  • Statins

Stage C: Symptomatic Heart Failure

Stage C, or symptomatic heart failure, is what most people think of as congestive heart failure. In stage C heart failure, there is an impairment of the heart that is causing symptoms, which may include:

  • Fatigue
  • Shortness of breath
  • Difficulty breathing when lying down flat
  • Waking up at night short of breath
  • Cough
  • Swelling in the lower extremities or abdomen
  • Weight gain
  • Palpitations
  • Light-headedness
  • Decreased appetite or feeling full sooner when eating

New York Heart Association Classification

Another classification system used in heart failure is the functional class, which is related to symptom severity and impact on daily life. This is known as the New York Heart Association Classification and includes:

  • Class 1: No impairment in physical activity
  • Class 2: Ordinary activity that causes mild symptoms, slight limitations in activity, no symptoms at rest
  • Class 3: Significant limitations due to symptoms with activity, no symptoms at rest
  • Class 4: Symptoms at rest, worsened with any physical activity

The ACC/AHA staging system often is combined with the NYHA class to provide a more detailed description of a particular person. For example, someone with stage C, NYHA class 2 heart failure, has symptomatic heart failure with a mild impairment of physical activity.

Progression and Survival in Stage C Heart Failure

Stage C heart failure can be stable for many years or can progress to stage D heart failure. One study found that over a three-year time frame, 4.5% of people with stage C heart failure with reduced ejection fraction progressed to stage D heart failure.

Overall five-year survival in stage C heart failure is about 75%, meaning 3 in 4 people are alive after five years. However, this varies by age and other underlying conditions.

Treatment

Treatment of stage C heart failure includes a number of medications depending on the individual situation:

  • Diuretics (fluid pills)
  • ACE inhibitors, ARBs, or an ARB+neprilysin inhibitor
  • Beta-blockers
  • Aldosterone antagonist
  • SGLT-2 inhibitor

Some people who have reduced ejection fraction may also benefit from placement of an implantable cardioverter-defibrillator (ICD).

Stage D: Advanced Heart Failure

Stage D Heart failure, also known as advanced heart failure or end stage heart failure, is the most severe form of heart failure, with significant symptoms that impact daily life and frequent hospitalizations despite medical treatment. Life expectancy is poor in people with stage D heart failure, which comes with a 20% five-year survival.

Treatment of Stage D Heart Failure

Treatment includes the same medications used in stage C heart failure, however they may not be tolerated well in stage D heart failure due to low blood pressure or side effects. In stage D heart failure, the following additional treatments may be considered:

  • Inotropes (medications given through a constant intravenous infusion that help the heart muscle contract, which may improve quality of life but can cause arrhythmias and lower overall survival)
  • Mechanical support device, such as left ventricular assist device (LVAD)
  • Heart transplant
  • Palliative care

A cardiologist, typically a cardiologist specializing in heart failure conditions, can discuss any advanced therapies such as LVAD or transplant that may be an option, taking into account your individual preferences and goals. Palliative care can be very helpful in managing symptoms and planning treatment and end-of-life concerns, regardless of whether advanced therapies are pursued.

How Quickly Does CHF Progress From Stage to Stage?

The progression of heart failure from stage to stage varies greatly and is not very predictable. Some people may never progress from stage A, whereas others might progress rapidly or over a period of many years. It all depends on the underlying cause of heart failure and other risk factors.

There are several models that assess risk that your cardiologist may use to help predict prognosis based on individual risk factors.

How to Prevent Heart Failure Progression

Progression of heart failure is not always in our control, but there are some things to do to keep the heart as healthy as possible. These include:

  • Getting regular physical exercise
  • Eating a heart-healthy diet, rich in fruits, vegetables, legumes, beans, and whole grains; and low in sodium, processed foods, trans fats, and sugars
  • Avoiding cigarette smoke
  • Controlling blood pressure, cholesterol, and blood sugar
  • Taking medications as directed by your healthcare provider

Coping with End-Stage Congestive Heart Failure

End-stage heart failure significantly impacts daily life, and it's important to work with your healthcare team to come up with a plan to help control symptoms and improve quality of life. Having a good support system and plan is important, and a palliative care team can play a great role in managing symptoms and planning.

Discuss with your care team if you are experiencing worsening symptoms, medication side effects, or symptoms of depression or anxiety since some medications or adjustments can be made to help you feel better.

Summary

Congestive heart failure is classified into four stages using the ACC/AHA staging system, which ranges from A to D. As heart failure progresses, symptoms appear and worsen, and life expectancy decreases. A cardiologist can help come up with an appropriate treatment plan to reduce your risk of heart failure progression and improve survival according to your individual circumstances.

Things to do to maintain a healthy heart include eating a heart-healthy diet, getting regular physical exercise, quitting smoking, and avoiding excessive alcohol.

The 4 Stages of Congestive Heart Failure (A, B, C, and D) and What They Mean (2024)

FAQs

What are the four stages of congestive heart failure? ›

Heart failure can progress, so researchers have identified four stages of the disease — A, B, C and D. Health care professionals also classify heart failure when it has progressed to stages C and D. This classification measures a patient's overall heart function and severity of symptoms.

What is the D stage of heart failure? ›

Stage D refers to the most advanced heart failure. “At this stage, you are typically very ill and are considering surgical treatments,” says Dr. Piña. “Symptoms like shortness of breath are interfering with daily life, even while you're at rest.”

What is Stage B congestive heart failure? ›

Stage B (pre-heart failure) means your left ventricle isn't working well and/or is structurally abnormal but you've never had symptoms of heart failure.

What are the stages of heart failure A B C D? ›

The ACC/AHA Stages of Heart Failure
ACC/AHA StageSymptoms
AAt high risk for heart failure but without structural heart disease or symptoms of heart failure.
BStructural heart disease but without signs or symptoms of heart failure.
CStructural heart disease with prior or current symptoms of heart failure.
1 more row
Jul 18, 2022

How long can you live with stage 4 congestive heart failure? ›

End stage heart failure is the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest. Symptoms may include shortness of breath, fatigue, and heart arrhythmias. The life expectancy for individuals with end stage heart failure is around 6–12 months.

How long does it take to go from stage C to stage D heart failure? ›

One out of eight outpatients with Stage C HFrEF receiving care in cardiology (including HF) clinics progressed to Stage D within 3 years, and another one out of eight died within the same period; in all, one out of four patients either died or progressed to Stage D within 3 years.

How long is Stage D heart failure? ›

Once heart failure progresses to stage D, people experience poor quality of life and high symptom burden and face a median life expectancy of only 6–12 months.

What are the four classifications of heart failure? ›

ACCF/AHA stages of HFNYHA functional classification
AAt high risk for HF but without structural heart disease or symptoms of HFNone
CStructural heart disease with prior or current symptoms of HFIII
IV
DRefractory HF requiring specialized interventionsIV
3 more rows

Is Stage 4 heart failure curable? ›

For most people, heart failure is a long-term condition that can't be cured. But treatment can help keep the symptoms under control, possibly for many years. The main treatments are: healthy lifestyle changes.

How do you know when congestive heart failure is end stage? ›

In the final stages of heart failure, people feel breathless both during activity and at rest. Persistent coughing or wheezing. This may produce white or pink mucus. The cough may be worse at night or when lying down.

Can stage B heart failure be reversed? ›

Can you reverse or fully recover from congestive heart failure? There's no cure for CHF. In some cases, though, significant lifestyle changes and medications can slow or reverse the course of CHF and improve cardiac function.

Can heart failure go back to normal? ›

Although heart failure is a serious condition that gets progressively worse over time, certain cases can be reversed with treatment. Even when the heart muscle is damaged, there are several treatments that can relieve symptoms and stop or slow them.

What is Stage 4 congestive heart failure? ›

Stage IV is the most advanced stage of heart failure. Patients have known systolic heart failure and advanced symptoms, even with drastic lifestyle changes and the highest level of care. While at rest, patients still experience symptoms of breathlessness and fatigue, and physical activity is likely not possible.

What is Grade C heart failure? ›

Stage C. People at this stage will show symptoms of HF linked to underlying structural heart disease, including fatigue or breathlessness. These symptoms usually occur due to problems with the squeezing function of the left ventricle or the pumping chamber of the heart.

At what stage of heart failure do you need a defibrillator? ›

So don't be alarmed if you look at your Epic report or your medical chart, and you see that ejection fraction is 50%. So 50% or higher is normal. And we start really worrying about sudden cardiac death, is when the ejection fraction is 35% or less. And then we should start considering a defibrillator.

How quickly does congestive heart failure progress? ›

It can severely limit the activities you're able to do and is often eventually fatal. But it's very difficult to tell how the condition will progress on an individual basis. It's very unpredictable. Lots of people remain stable for many years, while in some cases it may get worse quickly.

What are the symptoms of Stage 3 congestive heart failure? ›

Like Stage II of CHF, Stage III can be exacerbated by physical activity. However, symptoms are often much more severe. Shortness of breath, leg weakness, swelling of the lower body, fatigue, and reduced ability to exercise are all notable signs of this advanced stage.

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