HF Classification

There are two common systems for categorizing patients with HF. The New York Heart Association (NYHA) Functional Class (FC) system is based on the patient's activity level and exercise tolerance. It divides patients into one of four classes, with FC I patients exhibiting no symptoms or limitations of daily activities, and FC IV patients who are symptomatic at rest (Table 6-5). The NYHA FC system reflects a subjective assessment by a health care provider and can change frequently over short periods of time. FC correlates poorly with EF; however, EF is one of the strongest predictors of prognosis. In general, anticipated survival declines in conjunction with a decline in functional ability.

Table 6-4 Drugs That May Precipitate or Exacerbate HF

Agents Causing Negative Inotropic Effect

Antiarrhythmics (e.g., disopyramide, flecainide, and others) ß-Blockers (e.g., propranolol, metoprolol, atenolol, and others) Calcium channel blockers (e.g., verapamil and diltiazem) Itraconazole Terbinafine

Cardiotoxic Agents

Doxorubicin Daunomycin Cyclophosphamide

Agents Causing Sodium and Water Retention


COX-2 inhibitors Glucocorticoids Androgens Estrogens

Salicylates (high dose)

Sodium-containing drugs (e.g., carbenicillin disodium, ticarcillin disodium) Thiazolidinediones (e.g., rosiglitazone, pioglitazone)

COX-2, cyclooxygenase-2; NSAIDs, nonsteroidal anti-inflammatory drugs.

From Parker RB, Rodgers JE, Cavallari JH. Heart failure. In: DiPiro JT, Talbert RL, Yee GC, et al. (eds.) Pharmacotherapy: A Pathophysiologic Approach, 7th ed. New York: McGraw-Hill, 2008:180.

Table 6-5 NYHA Functional Classification and ACC/AHA Staging


NYHA AHA FC_Stage Description

N/A A Patients at high risk for HF but without structural heart disease or symptoms of HF

I B Patients with cardiac disease but without limitations of physical activity. Ordinary physical activity does not cause undue fatigue, dyspnea, or palpitation

II C Patients with cardiac disease that results in slight limitations of physical activity. Ordinary physical activity results in fatigue, palpitations, dyspnea, or angina

III C Patients with cardiac disease that results in marked limitation of physical activity. Although patients are comfortable at rest, less than ordinary activity will lead to symptoms

IV C, D Patients with cardiac disease that results in an inability to carry on physical activity without discomfort. Symptoms of HF are present at rest. With any physical activity, increased discomfort is experienced. Stage D refers to end-stage HF patients

ACC/AHA, American College of Cardiology/American Heart Association; FC, functional class; HF, heart failure; NYHA FC, New York Heart Association functional Class.

The American College of Cardiology/American Heart Association (ACC/AHA) has proposed another system based on the development and progression of the disease. Instead of classifications, patients are placed into stages A through D (Table 6-5).11 Because the staging system is related to development and progression of HF, it also proposes management strategies for each stage including risk factor modification. The staging system is meant to complement the NYHA FC system; however, patients can move between NYHA FCs as symptoms improve with treatment, whereas HF staging does not allow for patients to move to a lower stage (e.g., patients cannot be categorized as stage C and move to stage B after treatment). Currently, patients are categorized based on both systems. NYHA FC and ACC/AHA staging are useful from a clinician's perspective, allowing for a longitudinal assessment of a patient's risk and progress, requirements for nonpharmacologic interventions, response to medications, and overall prognosis.

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