Congestive heart failure classification
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Classification Schemes of Congestive Heart Failure
Framingham Criteria
Major Criteria
- Paroxysmal nocturnal dyspnea
- Jugular vein distention
- Rales
- Radiographic cardiomegaly
- Acute pulmonary edema
- S3
- Central venous pressure > 16 cmH2O
- Circulation time ≥ 25 sec
- Hepatojugular reflux
- Pulmonary edema
- Visceral congestion
- Cardiomegaly at autopsy
- Weight loss ≥ 4.5 kg in 5 days in response to treatment of heart failure
Minor Criteria
- Bilateral ankle edema
- Nocturnal cough
- Dyspnea on ordinary exertion
- Hepatomegaly
- Pleural effusion
- 30% decrease in baseline vital capacity
- Tachycardia
Boston Criteria of Congestive Heart Failure
- Category I: History
- Rest dyspnea 4 points
- Orthopnea 4 points
- Paroxysmal nocturnal dyspnea 3 points
- Dyspnea on walking on level ground 2 points
- Dyspnea on climbing 1 point
- Category II: Physical Examination
- Heart rate abnormality (1 point if 91 to 110 bpm; if >110 bpm, 2 points)
- Jugular venous pressure elevation (2 points if >6 cm H2O; 3 points if >6 cm H2O and hepatomegaly or edema))
- Lung crackles (1 point if basilar; 2 points if more than basilar)
- Wheezing 3 points
- Third heart sound 3 points
- Category III: Chest Radiography
- Alveolar pulmonary edema 4 points
- Interstitial pulmonary edema 3 points
- Bilateral pleural effusion 3 points
- Cardiothoracic ratio >0.50 (posteroanterior projection) 3 points
- Upper zone flow redistribution 2 points
No more than 4 points are allowed from each of three categories; hence the composite score (the sum of the subtotal from each category) has a possible maximum of 12 points.
The diagnosis of heart failure is classified as "definite" at a score of 8 to 12 points, "possible" at a score of 5 to 7 points, and "unlikely" at a score of 4 points or less.
New York Heart Association Criteria (NYHA)
- NYHA I: No symptoms with ordinary activity.
- NYHA II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or angina.
- NYHA III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.
- NYHA IV: Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency present at rest.
ACC/AHA Classification of Chronic Heart Failure
Classification System based on structural and symptomatic stages of the syndrome.
Introduced to emphasize the natural history of the heart failure syndrome and to identify ealier opportunities to intervene and prevent advancement. (Use along with NYHA starting when symptoms develop (Stages C-D). Stage A: patients at risk of developing heart failure but who have no structural heart disease at present. Stage B: patients with structural heart disease but no symptoms. Stage C: patients with structural heart disease and symptomatic heart failure. Stage D: patients with severe refractory heart failure.
Stage A
Patients “at Risk”
- Hypertension
- Diabetes mellitus
- Coronary artery disease
- Exposure history to cardiac toxins:
- History of cardiotoxic drug therapy.
- History of alcohol abuse.
- Familial history of cardiomyopathy
Stage B
Patients with structural heart disease, but no history of signs or symptoms of heart failure.
- Left ventricular hypertrophy (LVH)
- Myocardial fibrosis
- Left ventricular dilatation or dysfunction
- Asymptomatic valvular heart disease
- Previous myocardial infarction
Stage C
Underlying structural heart disease and symptoms of heart failure.
- Dyspnea or fatigue due to left ventricular systolic dysfunction.
- Asymptomatic patients receiving treatment for prior symptoms of heart failure.
Stage D
Despite of maximal medical therapy, symptoms of heart failure at rest and advanced structural heart disease.
- Being considered for advance options including LVAD and heart transplantation
- Requiring continuous inotropic or mechanical support
- Recieving or being considered for palliative care/end of life care.
References
2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. JACC 2009;xx: xx-xxx. Template:SIB