Right heart failure classification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby; Jad Z Al Danaf

Overview

There are many different ways to categorize right , which includes whether the abnormality is due to insufficient contraction (systolic dysfunction); or due to insufficient relaxation of the heart (diastolic dysfunction), or to both; whether the problem is primarily increased venous back pressure (preload), or failure to supply adequate arterial perfusion (afterload); whether the abnormality is due to low cardiac output with high systemic vascular resistance or high cardiac output with low vascular resistance (low-output heart failure vs. high output cardiac failure); degree of functional impairment conferred by the abnormality (as reflected in the New York Heart Association Functional Classification^[1]); and the degree of coexisting illness: i.e. heart failure/systemic hypertension, heart failure/pulmonary hypertension, heart failure/diabetes, heart failure/chronic renal failure, etc.

Right heart failure can be functionally classified according to the New york heart association functional classification – NYHA (I-IV) or structurally according to the American College of Cardiology/ American Heart Association – ACC/AHA (stage A, B, C and D).
The ACC staging system is useful in that Stage A encompasses “pre-heart failure” — a stage where intervention with treatment can presumably prevent progression to overt symptoms. ACC Stage A does not have a corresponding NYHA class. ACC Stage B would correspond to NYHA Class I. ACC Stage C corresponds to NYHA Class II and III, while ACC Stage D overlaps with NYHA Class IV.

Class I	No limitation is experienced in any activities; there are no symptoms from ordinary activities
Class II	Slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion
Class III	Marked limitation of any activity; the patient is comfortable only at rest
Class IV	Any physical activity brings on discomfort and symptoms occur at rest

Stage A	Patients at high risk for developing HF in the future but no functional or structural heart disorder
Stage B	A structural heart disorder but no symptoms at any stage
Stage C	Previous or current symptoms of heart failure in the context of an underlying structural heart problem, but managed with medical treatment
Stage D	Advanced disease requiring hospital-based support, a heart transplant or palliative care

↑ Criteria Committee, New York Heart Association. Diseases of the heart and blood vessels. Nomenclature and criteria for diagnosis, 6th ed. Boston: Little, Brown and Co., 1964;114.
↑ Hunt SA, Abraham WT, Chin MH; et al. (2005). “ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult” (PDF). Circulation. 112 (12): e154–235. doi:10.1161/CIRCULATIONAHA.105.167586. PMID 16160202.