Understanding the 4 Stages of Congestive Heart Failure

• Congestive heart failure is a type of heart disease characterized by fluid build-up attributed to weak pumping of the heart.
• Heart failure has four stages. The first two are associated with conditions that put you at high risk for heart failure prior to experiencing symptoms, whereas the latter two stages present symptoms and can be life-threatening.
• Treatment for heart failure varies by stage, though treatment plans often focus on managing symptoms and slowing the progression of this disease.

When the heart begins to fail, it rarely announces itself with severe or sudden symptoms. For most people, heart failure comes on slowly, and it's often hard to identify early on. To help with prompt diagnosis and treatment, the American Heart Association and the American College of Cardiology created four distinct stages of heart failure. Understanding these stages can be life-saving.

Continue reading for a better understanding of the four phases, including what a congestive heart failure diagnosis looks like, the ideal ways to treat heart failure by stage, and various ways to protect your heart in any state.

Multiple types of heart disease exist, and heart failure is one of the most common. Almost 6.7 million adults in the United States have this condition, and accounts for 14.6% of deaths overall. With heart failure, the heart doesn't stop beating, but there is fluid buildup that limits blood flow to and from the heart. Blood is pumped by the the heart delivering essential nutrients and oxygen to other parts of the body, which are then used to help the body function. When this is disrupted, it can cause symptoms throughout the body and damage organs and tissue.

A common subtype of heart failure is congestive heart failure . This occurs when the heart weakens, compromising its ability to pump blood effectively causing blood to backup in different parts of the body. Congestive heart failure sometimes comes on suddenly, though it's usually a chronic disease that gradually affects the heart's pumping ability.

Congestive heart failure may occur on the left or right side :

• Right-sided: When not enough blood is pumped from the heart to the lungs.
• Left-sided or systolic heart failure: This occurs when the left side of the heart becomes too weak, stiff, or tough and cannot pump oxygen-rich blood to the rest of the body.

Left-sided heart failure is more common. In some cases, both sides are affected. This is called biventricular heart failure.

If the onset is gradual, mild symptoms of heart failure appear at first, though these symptoms worsen significantly in the disease's fourth stage. Symptoms also differ depending on whether someone has left- or right-sided heart failure .

If someone has left-sided heart failure, they may experience symptoms such as:

• Shortness of breath
• Cough
• Fatigue
• Blueish color of lips or fingers
• Difficulty concentrating
• Feeling sleepy
• Unable to sleep when laying flat
• Chest pain

Symptoms of right-sided heart failure include the ones listed for left-sided heart failure, as well as:

• Nausea , or feeling sick to the stomach
• Loss of appetite
• Abdominal or stomach pain
• Swollen ankles, feet, belly, or neck veins
• Having to urinate more often
• Weight gain

The American College of Cardiology and the American Heart Association developed four stages to increase awareness of heart disease when it's highly treatable in it's asymptomatic phases (phase 1 and 2). These stages help cardiologists, doctors who specialize in heart health, and other medical providers deliver treatment as early as possible, potentially slowing the disease's progress and adding years onto patients' lives.

First Stage: Stage A

The first stage is classified as ​"at risk for heart failure." It applies to people who have multiple risk factors for this condition but do not currently have symptoms.

Second Stage: Stage B

The second stage is labeled ​"pre-heart failure." In this stage, people do not have symptoms at rest, although they may show symptoms during strenuous actvitity. In Stage B someone has structural heart disease or increased pressure in the heart.

Third Stage: Stage C

Once symptoms appear, someone is classified with ​"symptomatic heart failure." Someone remains in this stage, even if symptoms go away.

Final Stage: Stage D

The final stage is referred to as advanced heart failure or progressive heart failure. This is when severe heart failure interrupts someone's daily life, often resulting in hospitalization.

Heart failure means there isn't enough oxygen-rich blood flowing into the blood vessels throughout the body. This can lead to serious complications , such as:

• Breathing problems
• Kidney damage
• Liver damage
• Malnutrition, if fluid builds up, it can become difficult to eat
• Pulmonary hypertension, which affects the lungs' blood vessels
• Other heart conditions, like sudden cardiac arrest

If someone has heart failure, a healthcare provider will assess if they have any complications and address them in the patient's treatment plan.

If heart failure starts suddenly, it is typically caused by an injury to the heart or a medical condition that damages the heart muscle. When it develops slowly, it's usually due to another chronic medical condition that impacts heart function.

Common causes include:

Risk Factors for Congestive Heart Failure

While heart failure can happen to anyone, some factors increase the risk of developing it . Someone is at a higher risk if they:

• Are a man
• Are over the age of 65
• Have a family history of heart failure
• Are African American
• Have other medical conditions that increase the risk, including the ones listed above, as well as thyroid issues, sleep apnea, chronic kidney disease, and anemia.
• Take certain cancer treatments

Lifestyle factors also increase the risk and negatively influence overall heart health:

• Smoking
• Eating a diet that's high in fat, sodium, and/​or cholesterol
• Living an inactive lifestyle or not getting enough physical activity
• Misusing drugs
• Having an alcohol addiction
• Experiencing high stress levels often

There are a few different steps a provider may use to diagnose congestive heart failure such as exercise and blood tests.

Exercise Stress Test

Before researchers developed the four stages, doctors struggled to diagnose heart failure in stages one or two. Now, these stages allow for diagnosis based on risk factors, patient characteristics, and medical history. However, it is still difficult to assess the severity of stage C heart failure or end-stage heart failure.

Fortunately, there are clinical practice guidelines that can help. The New York Heart Association developed a classification system based on an exercise stress test in order to assess the severity of stage C and D heart failure:

• Classification One: Ordinary physical activity does not cause heart palpitations, difficulty breathing, or other changes.
• Classification Two: Comfortable when resting, though ordinary activity causes some fatigue, shortness of breath, or chest pain.
• Classification Three: Comfortable when resting, though any physical activity causes symptoms.
• Classification Four: Any physical activity causes discomfort, and there are also symptoms when resting.

While these four classifications can be confused with the four stages of heart failure, these classifications apply only to heart failure in stages C and D. They are often used to identify more severe symptoms.

Blood Tests

Along with an exercise test, a provider may order blood tests to check the level of certain molecules that indicate heart failure and an echocardiography, which provides an image of how much blood is pumped from the left ventricle into the heart. The amount of pumped blood is referred to as the ejection fraction:

Knowing this percentage helps a provider create an appropriate treatment plan, though it is possible, but rare, to have heart failure and a normal ejection fraction.

Diagnosing Chronic Heart Failure vs Congestive Heart Failure

All cases of congestive heart failure are chronic, but not all cases of chronic heart failure are congestive. Congestive involves fluid build-up. A cardiologist can use imaging tests, such as a cardiac CT scan or cardiac MRI , to determine the type of heart failure.

Are Advanced Heart Failure and Congestive Heart Failure the Same?

When traditional treatments no longer manage symptoms, someone has advanced heart failure, which could be considered the same as stage D. Congestive heart failure is a type of heart failure marked by fluid buildup. Both the stage of heart failure and type can be diagnosed by a cardiologist.

No matter the stage, a healthcare provider will monitor disease progression closely. Most people have check-ins with their provider every three to six months , though these appointments may be more often in heart failure's advanced stages.

Heart failure has no cure, but there are ways to relieve symptoms and slow the disease progression. A treatment plan may include:

• Lifestyle changes: eating a heart-healthy diet or moving more often than usual
• Cardiac rehab: a structured program that helps improve overall social, mental, and physical health
• Medications: blood thinners to prevent blood clots or drugs that lower blood pressure
• Devices or surgeries that help the heart work better: a ventricular assist device that helps pump blood from the lower chamber of the heart
• Cardiac resynchronization therapy: a treatment that helps with blood flow and the stabilization of someone's heartbeat

Stage A Treatment

In stage A, treatment focuses on lifestyle changes to support heart health. Someone may be prescribed medications to address risk factors, such as blood sugar medication for type 2 diabetes or medication for other types of heart disease.

A provider may recommend guideline-directed medical therapy (GDMT), a treatment that uses a combination of medications to lower blood pressure and manage hypertension. Typical medications for GDMT are:

• A thiazide diuretic
• An ACE inhibitor or ARB
• A calcium channel blocker.

Stage B Treatment

In stage B, additional medications may be prescribed, depending on someone's ejection fraction. For a fraction lower than 40% , beta blockers and angiotensin-converting enzyme inhibitors (ACEI) may help prevent heart failure from becoming symptomatic. Other medications may be prescribed to manage other medical conditions that are risk factors or causes of heart failure.

Depending on the individual, a cardiologist may begin to consider devices, surgeries, and cardiac rehab that may help, though these are more common in stage C. Heart-healthy habits are also important at this phase.

Stage C Treatment

Alongside lifestyle changes and medication, providers may recommend other steps to reduce all-cause mortality , including vaccines for respiratory illnesses, devices and surgeries to help the heart, and cardiac rehab. During stage C, cardiologists also screen patients for frailty, risk of depression, and access to social support.

A cardiologist will also determine which medications can help manage symptoms of heart failure or may help the heart pump blood more efficiently.

Stage D Treatment

Stage D heart failure is serious. A provider may focus efforts on ways to treat pain, which may include palliative or hospice care . For a select few patients, a heart transplant may be considered. Heart transplantation, however, isn't possible in every case and requires a healthy donor heart.

To reduce the risk of developing heart failure, take the same prevention steps to manage other types of heart disease.

Heart-healthy habits include:

• Eat a diet low in sodium, cholesterol, and saturated fats.
• Eat heart-healthy foods, such as minimally processed meat and carbs, and plenty of fruits and veggies.
• Manage stress levels . Strategies include meditation, breathwork, or making time for relaxing activities you enjoy, like reading or doing a puzzle.
• Meet the CDC's physical activity guidelines (150 minutes of aerobic movement at a minimum and two strength training sessions a week).
• Don't smoke or stop smoking.
• Check your cholesterol. If it's high, a healthcare provider can help you manage it.
• Control blood pressure . This can be done through medications, lowering stress levels, or eating less sodium.
• Manage diabetes or prediabetes, if you have either.
• Take any medications as directed by a healthcare provider

With the right treatment and mental health support, it is possible to live a meaningful life with heart failure. The exact outlook depends on how well someone follows their treatment plan, their exact symptoms, the stage of heart failure, and how symptoms respond to treatment.

However, once heart failure is symptomatic, it will probably impact daily life. Studies also place the five-year survival rate for symptomatic heart failure somewhere between 25-80% . Due to symptom severity, it's recommended to take care of your mental health as well as your physical health.

Mental health resources when dealing with heart failure include:

Some directories to find a therapist are:

What is the life expectancy of a person with congestive heart failure?

The life expectancy is shorter for someone with congestive heart failure than for someone without. One study suggests that heart failure reduces life expectancy by about 50% in people over 75. The exact reduction depends on many factors, including someone's age, the stage of heart failure, other medical conditions they have, and how they respond to heart failure treatment.

Does congestive heart failure have flare-ups?

Congestive heart failure may have flare-ups. These are defined as times when symptoms become so debilitating that the individual requires inpatient care.

How quickly does congestive heart failure progress?

There isn't a set timeline for how fast heart failure progresses. Someone's lifestyle, how they engage with treatment, other medical conditions, and how their symptoms respond to treatment all influence the progression rate.