The Classes and Stages of Heart Failure
Stuart Russell, MD, discusses the four classes and four stages of heart failure, including symptoms and treatment options for each.
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Learn more about Stuart Russell, MD
Stuart Russell, MD
Dr. Russell is board certified in cardiovascular disease and advanced heart failure/transplant cardiology and is dedicated to the care and treatment of advanced heart failure patients. He routinely performs right heart catheterizations and heart biopsies having performed more than 5,000 of each procedure.Learn more about Stuart Russell, MD
Transcription:
The Classes and Stages of Heart Failure
Bill Klaproth (Host): Hearing that you have heart failure can be a frightening experience. One way to reduce your fear and anxiety is to learn about the condition and your treatment options. So, let’s find out about the class system that cardiologists use to rank the stages of heart failure and what are the different treatment options. We’re going to find out with Dr. Stuart Russell, Director of Heart Failure at WakeMed Heart and Vascular. This is WakeMed Voices, a podcast from WakeMed Health and Hospitals. I’m Bill Klaproth. Dr. Russell what is the class system for heart failure and why do cardiologists need and or use this?
Stuart Russell, MD (Guest): So, the class system for heart failure is really kind of the oldest system that we have, and it really separates our patients based on their functional capacity. So, we really try to look at the symptoms that the patients are having and put patients into classes based on that. The benefit of this is it really helps us to understand where a patient is. So, we can think about a Class I patient differently than a Class IV patient. So, it’s almost like a shorthand for communicating to get a good feel for where patients are, where one doc to another can really have an idea about where their patient is and how to think about them.
Host: Right, that makes sense. So, in addition to the class system; I’ve also heard about a stage system. How are those different?
Dr. Russell: So, the stage system is a newer system which really kind of takes a patient through their journey. Where stage A patients are at risk for heart failure, stage B are those who actually have some reduction of function but no symptoms, stage 3 have symptoms and then stage 4 or excuse me, stage D are the end-stage patients. The difference between the two systems is the classes; if you get better, you can go from Class IV down to Class II. The stages, you always progress down this continuum. So, you go from stage A to B to C to D.
Host: So, that helps you rank the degree of heart failure. So, what are the four classes and then what are the four stages?
Dr. Russell: Sure so, the classes again, look at functional capacity. And so, Class I are patients with disease but really no symptoms. And by symptoms, we really focus on kind of what they do, right? So, are you short of breath with activity? And so if the answer to that is no; you are Class I. If you are short of breath with moderate activity, which in my mind is kind of walking around the store, walking through the mall, walking three to six blocks; then you are Class II. And you progress and get worse, short of breath with minimal activity; it’s Class III and minimal activity for me is can you carry groceries in from the car. Can you walk a flight of stairs. And then the Class IV patients are those who really are short of breath with almost no activity or at rest. So, are you getting short of breath getting dressed in the morning in my mind is a Class IV.
Flip flop that the other way to the stages and you’ve got stage A heart failure which are patients who are at risk for heart failure. And so these are people who have either coronary artery disease or diabetes or hypertension, so the risk factors for heart failure, but really haven’t manifested any signs of heart failure yet. Stage B are those when their heart isn’t functioning normally but have no symptoms. So, that would be similar kind of to a Class I patient. Stage C are those who both have functional reductions in function as well as symptoms. So, that’s your Class II and Class III patients. And then stage D heart failure is really the patients who are really at the end of the road and we are thinking about heart transplant or left ventricular assist devices and things like that for them.
Host: So, you were just talking about symptoms such as shortness of breath. Are there other symptoms that people would experience in each of these stages and or classes and what is their quality of life like in each?
Dr. Russell: The classifications are really kind of a functional type thing. And so it is what do you do with activities? So, from that aspect, I would say no. But as you go through these, there are similar things that patients get. So, patients that are Class I or Class II really are pretty good. But as they get to Class III, they’ll start to have swelling in their legs. They may get swelling in their abdomen and so they feel like they are always bloated. When they lay down at night; just having gravity kind of bring more fluid up towards their lungs; makes them short of breath. And so, they are propping up on two or three pillows to sleep or they wake up in the middle of the night short of breath. Class IV patients again, almost when they think about doing something, they start to get short of breath because they are so limited in terms of what their cardiac function reserve is.
Host: Okay, got it. So, let’s talk about treatment then. What methods of treatment do you use for each stage and class?
Dr. Russell: So, the kind of cornerstones of treatment for heart failure are meds. And from a class perspective; the differences in class to some extent are related to how much extra fluid patients have on board. And so, as they get symptomatic; a lot of those symptoms are related to having fluid and so we use diuretics to just get people to urinate out the extra fluid. Additionally, there is a lot of medications that we give them and so patients will be on a ACE inhibitor, a beta blocker, an aldosterone antagonist. Depending on the race, we may change their medicines that they are on. And so, there’s about four or five different meds that once patients hit Class II and Class III; they are always going to be on for kind of optimal medical therapy.
The nice thing about the stages now; in the past, we thought of stage A this kind of risk for heart failure as a group that wasn’t really within the heart failure domain. And all the guidelines they talk about preventing or treating the risk factors like we normally do but there was no kind of real heart failure specific stuff. Over the past year to two; there’s been a lot of data coming out with the new diabetic medications showing really a reduction in heart failure progression with some of these medications. And so, I think in contrast to five years ago, heart failure docs are really now focusing on diabetes and saying we need to make sure that patients with type 2 diabetes are on the right medications because it can really, I think make an impact in terms of whether they will or won’t progress to actually having heart failure.
Host: That’s a really interesting link. What about lifestyle changes for people that are in the lower classes? Is it possible to exercise more, eat better, stop drinking alcohol, stop smoking? Do those things help?
Dr. Russell: So, definitely smoking. There was a study that came out this summer that looked at there’s these seven kind of Life’s Simple 7 they called it, things that you can do. So, losing weight, exercising, having your diabetes treated, smoking, blood pressure, and of those seven; the things that seemed to have the biggest impact were stopping smoking, treating your blood sugar, and then the third was losing weight. And so, if you can get on those; and really work to get to a more healthier lifestyle; I think this is again, data from just following people over time but data that would suggest you are going to reduce your chances of having heart failure.
Host: Well that’s good to know. So, what services then do you offer at WakeMed to help patients in each of these stages and or classes?
Dr. Russell: Yeah so, I think the big thing that we do, is we take a look at each individual patient and say are you on the right medications. There’s a lot of medications that people are supposed to be on. A lot of times, they either have trouble getting on them or they just don’t want to do it because it’s a lot of different pills and so we add an extra layer of push to make that happen. We also have support from the pharmacists who will come to clinic and help you get up to the highest dose of medications because there’s some good data that higher doses are better than lower doses.
As you progress down and get worse; a lot of these patients end up getting hospitalized and one of the nice things that we have here is we can give IV diuretics. So intravenous diuretics in the clinic instead of having to go to the hospital. I got a call just last night about somebody who has gained 17 pounds. I think five years ago, she would have been sent to the emergency room and she’d be admitted right now. Instead, today, she’s going to come in and we are going to give her intravenous diuretics in our clinic and then if that’s doesn’t do the trick, she can come back tomorrow, she can come back the day after that. And so we can kind of do in-patient medicine as an outpatient.
Additionally, for those patients who are really at the end of the line; there’s a collaboration between Duke and WakeMed and so we can easily get patients worked up for heart transplant, for left ventricular assist devices and kind of some of those advanced therapies. Those are done at Duke but then they come back here for follow up at WakeMed after.
Host: Well it’s good to know about those advanced therapies and the collaboration that you have with organizations such as Duke. Dr. Russell, this has been fascinating. Thank you so much for your time today.
Dr. Russell: Oh thanks. My pleasure.
Host: That’s Dr. Stuart Russell, Director of Heart Failure at WakeMed Heart and Vascular. And to request an appointment with WakeMed Heart and Vascular Services or just to learn more please visit www.hearts.wakemed.og. That’s www.hearts.wakemed.org. And if you found this podcast helpful; please share it on your social channels and check out the full podcast library for topics of interest to you. I’m Bill Klaproth with WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. Thanks for listening.
The Classes and Stages of Heart Failure
Bill Klaproth (Host): Hearing that you have heart failure can be a frightening experience. One way to reduce your fear and anxiety is to learn about the condition and your treatment options. So, let’s find out about the class system that cardiologists use to rank the stages of heart failure and what are the different treatment options. We’re going to find out with Dr. Stuart Russell, Director of Heart Failure at WakeMed Heart and Vascular. This is WakeMed Voices, a podcast from WakeMed Health and Hospitals. I’m Bill Klaproth. Dr. Russell what is the class system for heart failure and why do cardiologists need and or use this?
Stuart Russell, MD (Guest): So, the class system for heart failure is really kind of the oldest system that we have, and it really separates our patients based on their functional capacity. So, we really try to look at the symptoms that the patients are having and put patients into classes based on that. The benefit of this is it really helps us to understand where a patient is. So, we can think about a Class I patient differently than a Class IV patient. So, it’s almost like a shorthand for communicating to get a good feel for where patients are, where one doc to another can really have an idea about where their patient is and how to think about them.
Host: Right, that makes sense. So, in addition to the class system; I’ve also heard about a stage system. How are those different?
Dr. Russell: So, the stage system is a newer system which really kind of takes a patient through their journey. Where stage A patients are at risk for heart failure, stage B are those who actually have some reduction of function but no symptoms, stage 3 have symptoms and then stage 4 or excuse me, stage D are the end-stage patients. The difference between the two systems is the classes; if you get better, you can go from Class IV down to Class II. The stages, you always progress down this continuum. So, you go from stage A to B to C to D.
Host: So, that helps you rank the degree of heart failure. So, what are the four classes and then what are the four stages?
Dr. Russell: Sure so, the classes again, look at functional capacity. And so, Class I are patients with disease but really no symptoms. And by symptoms, we really focus on kind of what they do, right? So, are you short of breath with activity? And so if the answer to that is no; you are Class I. If you are short of breath with moderate activity, which in my mind is kind of walking around the store, walking through the mall, walking three to six blocks; then you are Class II. And you progress and get worse, short of breath with minimal activity; it’s Class III and minimal activity for me is can you carry groceries in from the car. Can you walk a flight of stairs. And then the Class IV patients are those who really are short of breath with almost no activity or at rest. So, are you getting short of breath getting dressed in the morning in my mind is a Class IV.
Flip flop that the other way to the stages and you’ve got stage A heart failure which are patients who are at risk for heart failure. And so these are people who have either coronary artery disease or diabetes or hypertension, so the risk factors for heart failure, but really haven’t manifested any signs of heart failure yet. Stage B are those when their heart isn’t functioning normally but have no symptoms. So, that would be similar kind of to a Class I patient. Stage C are those who both have functional reductions in function as well as symptoms. So, that’s your Class II and Class III patients. And then stage D heart failure is really the patients who are really at the end of the road and we are thinking about heart transplant or left ventricular assist devices and things like that for them.
Host: So, you were just talking about symptoms such as shortness of breath. Are there other symptoms that people would experience in each of these stages and or classes and what is their quality of life like in each?
Dr. Russell: The classifications are really kind of a functional type thing. And so it is what do you do with activities? So, from that aspect, I would say no. But as you go through these, there are similar things that patients get. So, patients that are Class I or Class II really are pretty good. But as they get to Class III, they’ll start to have swelling in their legs. They may get swelling in their abdomen and so they feel like they are always bloated. When they lay down at night; just having gravity kind of bring more fluid up towards their lungs; makes them short of breath. And so, they are propping up on two or three pillows to sleep or they wake up in the middle of the night short of breath. Class IV patients again, almost when they think about doing something, they start to get short of breath because they are so limited in terms of what their cardiac function reserve is.
Host: Okay, got it. So, let’s talk about treatment then. What methods of treatment do you use for each stage and class?
Dr. Russell: So, the kind of cornerstones of treatment for heart failure are meds. And from a class perspective; the differences in class to some extent are related to how much extra fluid patients have on board. And so, as they get symptomatic; a lot of those symptoms are related to having fluid and so we use diuretics to just get people to urinate out the extra fluid. Additionally, there is a lot of medications that we give them and so patients will be on a ACE inhibitor, a beta blocker, an aldosterone antagonist. Depending on the race, we may change their medicines that they are on. And so, there’s about four or five different meds that once patients hit Class II and Class III; they are always going to be on for kind of optimal medical therapy.
The nice thing about the stages now; in the past, we thought of stage A this kind of risk for heart failure as a group that wasn’t really within the heart failure domain. And all the guidelines they talk about preventing or treating the risk factors like we normally do but there was no kind of real heart failure specific stuff. Over the past year to two; there’s been a lot of data coming out with the new diabetic medications showing really a reduction in heart failure progression with some of these medications. And so, I think in contrast to five years ago, heart failure docs are really now focusing on diabetes and saying we need to make sure that patients with type 2 diabetes are on the right medications because it can really, I think make an impact in terms of whether they will or won’t progress to actually having heart failure.
Host: That’s a really interesting link. What about lifestyle changes for people that are in the lower classes? Is it possible to exercise more, eat better, stop drinking alcohol, stop smoking? Do those things help?
Dr. Russell: So, definitely smoking. There was a study that came out this summer that looked at there’s these seven kind of Life’s Simple 7 they called it, things that you can do. So, losing weight, exercising, having your diabetes treated, smoking, blood pressure, and of those seven; the things that seemed to have the biggest impact were stopping smoking, treating your blood sugar, and then the third was losing weight. And so, if you can get on those; and really work to get to a more healthier lifestyle; I think this is again, data from just following people over time but data that would suggest you are going to reduce your chances of having heart failure.
Host: Well that’s good to know. So, what services then do you offer at WakeMed to help patients in each of these stages and or classes?
Dr. Russell: Yeah so, I think the big thing that we do, is we take a look at each individual patient and say are you on the right medications. There’s a lot of medications that people are supposed to be on. A lot of times, they either have trouble getting on them or they just don’t want to do it because it’s a lot of different pills and so we add an extra layer of push to make that happen. We also have support from the pharmacists who will come to clinic and help you get up to the highest dose of medications because there’s some good data that higher doses are better than lower doses.
As you progress down and get worse; a lot of these patients end up getting hospitalized and one of the nice things that we have here is we can give IV diuretics. So intravenous diuretics in the clinic instead of having to go to the hospital. I got a call just last night about somebody who has gained 17 pounds. I think five years ago, she would have been sent to the emergency room and she’d be admitted right now. Instead, today, she’s going to come in and we are going to give her intravenous diuretics in our clinic and then if that’s doesn’t do the trick, she can come back tomorrow, she can come back the day after that. And so we can kind of do in-patient medicine as an outpatient.
Additionally, for those patients who are really at the end of the line; there’s a collaboration between Duke and WakeMed and so we can easily get patients worked up for heart transplant, for left ventricular assist devices and kind of some of those advanced therapies. Those are done at Duke but then they come back here for follow up at WakeMed after.
Host: Well it’s good to know about those advanced therapies and the collaboration that you have with organizations such as Duke. Dr. Russell, this has been fascinating. Thank you so much for your time today.
Dr. Russell: Oh thanks. My pleasure.
Host: That’s Dr. Stuart Russell, Director of Heart Failure at WakeMed Heart and Vascular. And to request an appointment with WakeMed Heart and Vascular Services or just to learn more please visit www.hearts.wakemed.og. That’s www.hearts.wakemed.org. And if you found this podcast helpful; please share it on your social channels and check out the full podcast library for topics of interest to you. I’m Bill Klaproth with WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. Thanks for listening.