Heart Failure
Whistle Stop Talks
No. 2
Classification Implications
Susie Bowell BA Hons, RGN
Heart Failure Specialist Nurse
Implications of
classification
Most commonly used is the New York Heart Association (NYHA), however
the NYHA does not take into consideration the progression of HF from risk
factors through asymptomatic dysfunction through to death.
Accurate and appropriate classification reflects the changing
understanding of the disease process and underlies –
–
–
–
–
–
–
–
–
–
Patient Care
Study design and future research
Acknowledgement of HF as a progressive disease process
Early detection , recognition and prevention
Presumed prevalence figures
Disease understanding
Treatment staging
Prognostic assessment and understanding
Public Health education, future health economics and health systems.
The New York Heart Association
(nyha) definition
Classification
NYHA Class 1
Symptoms
No limitations of physical activity. No heart
failure symptoms
NYHA Class 2
Mild limitation of physical activity. Heart
Failure symptoms with significant exertion;
comfortable at rest or with mild activity
Marked limitation of physical Activity.
Heart Failure symptoms with mild exertion;
only comfortable at rest
NYHA Class 3
NYHA Class 4
Discomfort with any activity
American Heart Association and
American College of Cardiology
(AHA and ACC)
• In recognition that the development of HF is now considered
to lie on a continuum, the AHA and ACC have devised a
staging classification which emphasises this progression and
the importance of early detection and prevention from
asymptomatic disease to end stage heart failure.
• Increasingly, population studies are taking into consideration
risk factors and asymptomatic dysfunction when designing
studies on HFrEF and HFpEF
American Heart Association/American College of
Cardiology (AHA/ACC) Stages of HF
HF STAGE
AHA/ACC GUIDELINE DESCRIPTION
A
Patients at high risk of developing HF because of the presence of a
condition strongly associated with the development of HF. Such
patients have no identified structural or functional abnormalities of
the pericardium, myocardium, or cardiac valves and have never
shown signs or symptoms of HF
B
Patients with structural heart disease that is strongly associated
with the development of HF but without HF signs or symptoms
C
Patients with prior or current symptoms of HF associated with
underlying structural heart disease
D
Patients with advanced structural heart disease and refractory
symptoms of HF requiring specialised interventions
ACC/AHA STAGES FOR TREATMENT
Killip classification
The Killip classification may be used to describe the severity of
the patient’s condition in the acute setting after myocardial
infarction
Killip classification is an independent predictor of early
mortality after myocardial infarction (MI), and the presence
of left ventricular systolic dysfunction (left ventricular
ejection fraction <50%) and high Killip class predicts poor
short-term prognosis
Killip class is a strong predictor of long-term mortality, and
patients with high Killip class and left ventricular systolic
dysfunction post MI are at highest risk
Killip classification
• Killip class I includes individuals with no clinical signs of
heart failure
• Killip class II includes individuals with rales or crackles
in the lungs, an S3, and elevated jugular venous
pressure.
• Killip class III describes individuals with frank acute
pulmonary oedema.
• Killip class IV describes individuals in cardiogenic shock
or hypotension (measured as systolic blood pressure
lower than 90 mmHg), and evidence of peripheral
vasoconstriction (oliguria, cyanosis or sweating).
Problems with
classification
• NYHA classification rarely remains static for patients and can change over
a relatively short period of time even in the absence of medication/
treatment changes.
• Patients may present acutely with 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 under-treatment of some patients with severe LV
dysfunction who might be only mildly symptomatic.
2
• This is when the AHA/ACC staging may be considered useful as a guideline
for treatment purposes as it takes into consideration underlying structural
changes and not simply patient symptoms. This staging is not currently
used within the NICE or ESC guidelines for heart failure, however, the
treatments advised are the same and may be used to assist understanding
in the staging of HF treatment when a patients symptoms alter.
Important to note
Symptom severity correlates poorly with structural ventricular
function
Although there is a clear relationship between severity of
symptoms and patient survival, patients with mild symptoms
may still have a relatively high risk of hospitalization and
sudden death.
bibliography
•
•
•
•
•
•
1. NICE Heart Failure Guidelines 2010
2.European Society of Cardiology Heart Failure Guidelines 2012
3. Management of Asymptomatic Patients with Reduced Left Ventricular Ejection Fraction, Heart Failure Society of America Guidelines,
2010
4. Vinereanu D, Nicolaides E, Tweddel A. C, Fraser A. G. (2005). “Pure” diastolic dysfunction is associated with long-axis systolic
dysfunction. Implications for the diagnosis and classification of heart failure. European Journal of Heart Failure >Volume 7, Issue 5> Pp.
820-828
5. Parakh K, Thombs BD, Bhat U, Fauerbach JA, Bush DE, Ziegelstein RC. (2008) Long-term Significance of Killip Class and Left Ventricular
Systolic Dysfunction
American Assocation of Caridiology and American Heart Failure Association Guidelines