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ACC/AHA Heart Failure Staging

Describes stages of heart failure and provides recommendations for therapy by stage.

This tool reflects general recommendations found in the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. For more detailed guideline statements and advanced therapies, view the full guideline. 

Patient with history of hypertension, cardiovascular disease, diabetes, or obesity

Patient using cardiotoxins

Patient with genetic variant for cardiomyopathy or family history of cardiomyopathy

Result:

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Management

Below is a summary of Class I recommendation statements. This list focuses on goal directed medical therapy (GDMT) and does not contain all guideline statements. Refer to the full guideline text for further details and management options. 

Stage A: Patients at high risk of developing HF because of the presence of conditions that are strongly associated with the development of HF. 

  1. In patients with HTN, blood pressure should be controlled with GDMT for HTN to prevent symptomatic heart failure. (LOE: A)

  2. In patients with type 2 diabetes mellitus and either established CVD or who are at high cardiovascular risk, an SGLT2i should be used to prevent hospitalizations for heart failure. (LOE: A)

  3. Healthy lifestyle habits such as regular physical activity, maintaining normal weight, following a healthy diet, and avoiding smoking are helpful to reduce future risk of heart failure. (LOE: B-NR)

  4. In patients with CVD, optimal management is recommended. 

  5. In patients with exposure to cardiotoxic agents, multidisciplinary management is recommended.

  6. For patients who have first-degree relatives with genetic or inherited cardiomyopathies, genetic screening and counseling is recommended.

Stage B: Patients who have developed structural heart disease that is strongly associated with the development of HF but who have never shown signs or symptoms of HF.

  1. In patients with LVEF <40%, treatment with an ACEi is recommended to prevent symptomatic heart failure and reduce mortality. (LOE: A)

  2. In patients with a recent or remote history of MI or ACS, statins should be used to prevent symptomatic heart failure and adverse cardiovascular events. (LOE: B-R)

  3. In patients with a recent MI and LVEF <40%, treatment with an ARB is recommended if an ACEI is not tolerated. (LOE: A)

  4. In patients with LVEF <40% and a recent or remote history of MI or ACS, evidence-based beta blocker therapy is recommended. (LOE: B-R)

  5. In patients with an LVEF <30%, >1 year survival, > 40 days post MI, treatment with an ICD is recommended to reduce mortality and for primary prevention of sudden cardiac death. (LOE: B-R)

  6. In patients with LVEF <40%, beta blockers should be used to prevent symptomatic heart failure. (LOE: C-LD)

Stage C: Patients who have current or prior symptoms of HF associated with underlying structural heart disease.

  1. In patients who have fluid retention, diuretics are recommended to relieve congestion, improve symptoms, and prevent worsening heart failure. (Level of Evidence: B-NR)

  2. In patients with HFrEF and NYHA class II or III symptoms, the use of an ARNi is recommended to reduce morbidity and mortality. (LOE: A)

  3. The use of ACEi is beneficial to reduce morbidity and mortality when use of an ARNi is not feasible. (LOE: A)

  4. The use of an ARB is recommended only if intolerant to an ACEi or ARNi. (LOE: A)

  5. In patients with chronic symptomatic HFrEF NYHA class II or III who are able to tolerate ACEi or ARB, replacement with an ARNi is recommended to further reduce morbidity and mortality. (LOE: B-R)

  6. If a beta blocker is indicated, use of bisoprolol, carvedilol or metoprolol succinate is recommended to reduce mortality and hospitalizations. (LOE: A)

  7. In patients with HFrEF and NYHA class II-IV symptoms, spironolactone or eplerenone is recommended to reduce morbidity and mortality. (LOE: A) eGFR should be >30 ml/min/1.73m2 and serum potassium should be <5.0 mEq/L.

  8. In patients with symptomatic chronic HFrEF, SGLT2i are recommended to reduce hospitalizations for heart failure and cardiovascular mortality, regardless of the presence or absence of type 2 diabetes. (LOE: A)

  9. For patients who self-identify as African American, who have NYHA class III-IV HFrEF, and who are receiving optimal medical therapy, the combination of hydralazine and isosorbide dinitrate is recommended to improve symptoms and reduce morbidity and mortality. (LOE: A)

Stage D: Patients with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy and who require specialized interventions.

  1. In patients with advanced heart failure, timely referral for HF specialty care is recommended (if consistent with patient’s goals) to review management and advanced HF therapies. (LOE: C-LD)

  2. In select patients with advanced HFrEF with NYHA class IV symptoms who are deemed to be dependent on continuous IV inotropes or temporary MCS, durable LVAD implantation is effective to improve functional status, QOL, and survival. (LOE: A)

  3. For selected patients with advanced HF despite GDMT, cardiac transplantation is indicated to improve survival and QOL. (LOE: C-LD)

  4. In patients hospitalized with HF, severity of congestion and adequacy of perfusion should be assessed to guide triage and initial therapy. (LOE: C-LD)

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