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What Are The 4 Stages of Heart Failure?

by Prity Kumari
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Heart failure or congestive heart failure is a cardiac condition wherein the heart is unable to pump enough oxygen-rich blood to all body tissues and organs because of stiffness of heart muscles or it becoming too weak. As organs and tissues are not able to receive blood and other nutrients, eventually their functioning gets affected.

Heart failure can’t be understood as the stopping of a heartbeat rather it is just a condition where the heart is not able to work normally as it should. [1, 2]

What causes Heart Failure?

There are several factors contributing to heart failure, including:

  • Hypertension- Due to high blood pressure, extra strain can be put on the heart and if not controlled by medications, the patient can get heart failure.
  • Arrhythmias- These are abnormal cardiac rhythms such as atrial fibrillation wherein the patient has a persistent fast heart rate that impairs the contraction strength of the heart and causes less efficient pumping of the heart.
  • Coronary Artery Disease- It is a medical condition where the arteries that supply blood to the heart get clogged usually because of the deposits of bad cholesterol.
  • Cardiomyopathy- It refers to the inherited or acquired conditions that affect the heart muscles leading to failure of heart function.
  • Congenital Heart Disease- It refers to all birth defects that impair the normal working of the heart.
  • Heart Valve Disease- It is a condition where the heart valves either get damaged or have a defect that increases the volume and strain on the heart, hence weakening it and leading to its failure.
  • Toxicity- Certain chemotherapy drugs and excess intake of alcohol can be toxic for heart muscle cells and result in their non-functioning or malfunctioning.
  • Metabolic Disorders- There are some endocrine causes of heart failure including diabetes and hyperthyroidism with an overactive thyroid.
  • Others- Obesity and behaviors like having a diet rich in cholesterol and sodium, a sedentary lifestyle, and smoking. [1]

Stages of Heart Failure

According to the degree of symptoms or functional limits, there are 4 stages of heart failure named as Stage A, Stage B, Stage C, and Stage D.

Stage A

The patients having stage A heart failure are the ones considered to be at high risk of developing heart failure. This means they neither have heart failure nor its symptoms. It can be because of factors including:

  • Family history
  • Heart attack
  • Coronary Artery Disease
  • Hypertension
  • Diabetes
  • Obesity
  • Metabolic syndrome
  • Earlier records of having rheumatic fever
  • Past history of drinking too much alcohol
  • History of intake of drugs that can damage the heart muscles like cancer medications.

Stage B

The patients falling under this stage have asymptomatic or silent heart failure. They have been diagnosed via echocardiogram (echo) for some structural changes in the heart such as systolic left ventricular dysfunction which is strongly associated with developing heart failure. People with stage B heart failure usually show an ejection factor (EF) of 40 percent or less on echo.

Stage C

When the patients experiencing structural changes in the hearts start to exhibit symptoms of heart failure, they are considered to be Stage C heart failure patients. Such patients either currently have signs and symptoms of heart failure or previously had them. The most common symptoms that the patients can expect to see include:

  • Nausea
  • Fatigue or extreme tiredness
  • Weakness
  • Dizziness
  • Lightheadedness
  • Coughing and wheezing
  • Increased urge to urinate at night
  • Inability to exercise
  • Shortness of breath or breathing problems
  • Difficulty in concentrating
  • Rapid or irregular heartbeat even when the body is at rest
  • Weight gain
  • Swollen ankles, feet, lower legs, and even abdomen (edema).

Stage D

Patients are considered to be in stage D heart failure when their heart failure symptoms fail to respond to treatments and require aggressive medical therapy. It is the advanced or final stage of heart failure. The patients are likely to show extreme cases of symptoms as mentioned in stage C heart failure at rest or on mild/minimal exertion. [1, 2. 3]

The Treatment Plan For Each Stage Of Heart Failure

Heart failure can be treated based on the stage at which heart failure is determined by the doctor.

Stage A Treatment

As it is a pre-heart failure stage, the primary treatment plan includes preventive measures such as:

  • Smoking cessation
  • No alcohol abuse or usage of recreational drugs
  • Treatment for high cholesterol with drugs
  • Doing regular cardio exercises, being active and fit
  • Treatment for hypertension through intake of a low sodium diet, lifestyle modification, and certain medications to control high blood pressure
  • Taking medications to treat underlying health issues like diabetes.

Stage B Treatment

The usual treatment plan would include all the treatments/ preventive measures listed in stage A treatment along with the medications used to treat heart failure such as:

  • Angiotensin-Converting Enzyme Inhibitor (ACE-I)
  • Angiotensin II receptor blockers (ARB), also called angiotensin-2 receptor antagonists
  • Beta-blockers also called beta-adrenergic blocking agents- for patients who had a heart attack and their ejection factor is 40% or less
  • Aldosterone antagonists- for patients who had a heart attack or have diabetes and ejection factor of 30% or less
  • SGLT2 inhibitor medication
  • Other medications based on the presence of other health issues in the patients such as blood thinners (anticoagulants), statins (cholesterol-lowering drugs), and dig-oxin

For those having coronary artery disease, valve disease, or a heart attack, possible surgeries or interventions are provided for their treatment.

Stage C Treatment

The treatment plan includes the treatments listed for stage A and Stage B heart failure patients along with other treatments as listed below:

  • Angiotensin-receptor neprilysin inhibitors (ARNIs)
  • Prescribed diuretics (water pills)- if symptoms persist
  • Channel blockers
  • Possible fluid restriction
  • Medications to bring the fast heart rate back to normal i.e. 70 beats/min
  • Hydralazine and isosorbide dinitrate combination-specifically meant for African-Americans having moderate to severe heart failure symptoms when other treatments are not able to provide relief
  • Assess fluid retention by keeping track of body weight
  • Placement of biventricular pacemaker- a possible cardiac resynchronization therapy
  • Possible implantable cardiac defibrillator therapy.

Stage D Treatment

The usual treatment plan includes treatments of the other three stages of heart failure along with evaluation for more advanced treatment options, such as:

  • Left ventricular assist devices
  • Heart surgery
  • Heart transplantation
  • Valve replacement surgery
  • Percutaneous coronary intervention or angioplasty
  • Continuous infusion of intravenous inotropic drugs
  • Hospice or palliative care or research therapies. [1, 2]


  1. https://www.topdoctors.co.uk/ medical-articles/understanding-4-stages-heart-failure
  2. https://www.emedicinehealth.com/ what_are_the_4_stages_of_congestive _heart_failure/article_em.htm
  3. https://www.midgaheart.com/blog/ advanced-cardiology-what-are-the-4-stages-of-congestive-heart-failure/

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