Classification of heart failure

There are many heart failure classifications being used. These classifications are used in order to help with a better understanding of the different stages and the treatment of the various stages.

Here, two of the most common classifications will be described:

The first classification separates patients into 4 classes (adapted from the New York Heart Association (NYHA) as detailed in (Inamdar et al., 2016))

• Class I: This includes patients with various types of cardiomyopathies, but without any loss of physical capability, ordinary physical activity does not cause symptoms.
• Class II: patients do not display dyspnea or any other symptoms when practicing light exercise, but functional symptoms are only apparent after intense physical exertion. Heart failure causes slight limitations in physical activity, but patients are comfortable at rest.
• Class III: functional symptoms of heart failure are emergent during any kind of exertion, however light they may be, marked limitations of physical activity, patients are comfortable at rest but less than ordinary activity causes symptoms of HF.
• Class IV: patients exhibit signs of heart failure even at rest, but they become more severe during exertion, however, light it may be. Patients are unable to carry on any physical activity without heart failure symptoms.

The second classification separates the condition into three stages:

Stage 1: Is characterized only by changes in the heart cavities, and usually representative of the latent stage of heart failure.
Those suffering from the condition at Stage 1 display:

• Dyspnea
• Palpitation
• Tachycardia (only during exertion)

Stage 2: is separated into Stage 2A and Stage 2B.

Stage 2A: Patients must sleep using a tall pillow, due to their dyspnea bothering them even while resting. They experience palpitations, hence they cannot sleep on their left side.  They also experience:

• A sensation of heaviness in their right hypochondrium, as a consequence of a liver enlargement;
• Malleolar edema  (around the ankles) emerging from the very onset appear in the evening and disappear in the morning, and later on, the edemas become stable and spread to the shins and to the lumbosacral region. Patients also suffer from:
• Cyanosis
• Tachycardia
• Stasis rales in the lungs
• Signs of renal stasis (albuminuria, hyaline cylinders, and high-density urine)

Stage 2B: The symptoms mentioned above become more accentuated, the patients exhibit:

• Orthopnea (they have difficulties breathing if they sit in any other position than upright)
• A cough with hemoptoic (with blood) sputum, which also contains the so-called cardiac cells, etc.

Upon an objective examination the patients exhibit:

• cyanosis
• generalized edema, or anasarca (edema in the entire body)
• the heart is enlarged in all directions, it is called cor bovinum
• heart rhythm problems
• hepatomegaly
• renal stasis, oliguria, nicturia (reduction of urination during the day and night)
• respiration of the Cheyne-Stokes type, as a consequence of cerebral perturbation, etc.

An important symptom that differentiates Stage 2A from Stage 2B is the accumulation of transudate in the serous cavities; ascites, hydrothorax, and less commonly hydro pericarditis.

Stage 3 is characterized by:

• Dystrophic changes (in various organs)
• The liver becomes sclerotic and cardiac cirrhosis develops
• Portal hypertension
• Spleen enlargement
• Varicose esophagus and hemorrhoids
• Irreversible ascites
• The skin becomes dry, the subcutaneous tissue disappears, the muscles become atrophied, the patients become cachectic (lose a lot of muscle mass, lose weight, and suffer from hypothermia. The heart is enlarged in all directions and a systolic noise is heard at the tricuspid valve as a consequence of its functional insufficiency. In this condition, the heart cannot compensate.

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