Stage B Heart Failure

Abstract

Heart failure (HF) is a clinical syndrome characterized by symptoms of effort intolerance (eg, dyspnea and fatigue) and/or signs of fluid retention (eg, pulmonary congestion and peripheral edema) due to a variety of pathological processes that perturb normal cardiac function. Approximately 50% of HF patients present with evidence of left ventricular systolic dysfunction (LVSD) manifested as a low left ventricular ejection fraction (LVEF); the remaining half are found to have preserved left ventricular (LV) function.1 HF with either low or normal LVEF represents a significant contemporary medical problem that affects an estimated 5 million people in the United States, with an annual mortality rate approaching 20%.2 HF is considered a progressive disorder that can be represented as a clinical continuum. The American College of Cardiology/American Heart Association (ACC/AHA) updated 2005 guidelines for the management of chronic HF identify 4 stages in this continuum (Figure 1)3 and link the stages in the natural history of HF to therapeutic recommendations for each stage. Previously, the New York Heart Association (NYHA) functional classification, based solely on the severity of symptoms (primarily of patients in ACC/AHA stage C or D), was used as a criteria to initiate or change HF therapy. NYHA classification can change over a relatively short period of time even in the absence of medication changes. Nearly every patient who presents to an emergency department for care has at least NYHA class III or IV symptoms; however, at discharge after treatment, many patients are minimally symptomatic. Clinicians must then decide whether to apply NYHA class IV therapies or only class II therapies, which leads to some uncertainty. This approach may result in the undertreatment of some patients with severe LV dysfunction who might be only mildly symptomatic. Figure 1. ACC/AHA guidelines for the evaluation and management of …