They symptoms of heart failure are commonly graded according to New York Heart Association (NYHA) classification (table).

Patients may shift from one class to another, in either direction over time.

A newer system classifies patients according to their stages in the temporal course of heart failure. In this system, progression is in only one direction (from Stage A to Stage D) reflecting the typical sequence of heart failure manifestations in clinical practice Stage A Stage B Stage C Stage D Patient at risk of developing heart failure but has not yet developed structural cardiac dysfunction (patient with CAD, HTN or family history of cardiomyopathy) Patient with structural heart disease associated with heart failure but has not yet developed symptoms Patient who has current or prior symptoms of heart failure associated with structural heart disease Patient who has sturucral heart disease and marked heart failure symptoms despite maximal medical therapy and requires advance cardiac transplntation

9.4a: Prophylactic ICD placement should be considered in patients with LVEF <=35% and mild to moderate HF symptoms: Ischemic etiology (Strength of Evidence = A) Non-ischemic etiology (Strength of Evidence = B) See Recommendation 9.1 for additional criteria. 9.4b: In patients who are undergoing implantation of a biventricular pacing device according to the criteria in recommendations 9.7-9.8, use of a device that provides defibrillation should be considered. (Strength of Evidence = B) See Recommendation 9.1 for additional criteria. 9.5 ICD placement is not recommended in chronic, severe refractory HF when there is no reasonable expectation for improvement or in patients with a life expectancy of less than 1 year. (Strength of Evidence = C)

Comparison of three methods of assessing cardiovascular disability Class

I

New York Heart Association [1] functional classification

Patients with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, anginal pain. Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.

Canadian Cardiovascular Society [2] functional classification

Ordinary physical activity (walking & climbing stairs) does not cause angina. Angina with strenuous or rapid prolonged exertion at work or recreation.

Can perform any [3] activity requiring:

carry 24 lb, climb up 8 steps; do outdoor work (shovel snow, spade soil); skiing, basketball, handball, jog/walk 5 mph sexual intercourse without stopping, garden, rake, weed, roller skate, dance fox trot, walk at 4 mph on level ground

II

Slight limitation of ordinary activity. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, or when under emotional stress, or only during the few hours after awakening. Walk > two blocks on the level, climb > 1 flight of stairs at a normal pace and in normal conditions. Marked limitation of ordinary physical activity. Walking one to two blocks on the level and climbing one flight in normal conditions.

III

Patients with cardiac disease resulting in marked limitation of physical activity. Comfortable at rest; Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain. Patient with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or of anginal syndrome may be present even at rest. Discomfort increased with any physical activity undertaken

shower without stopping, strip & make bed, clean windows, walk 2.5 mph, bowl, play golf, dress without stopping,

Inability to carry on any physical activity without discomfort - anginal syndrome may be present at rest.

Patients cannot or do not perform to completion activities requiring >2 ME. Cannot carry out activities listed above (Specific activity scale III).

Class I - There is evidence and/or general agreement that the following approaches are effective in the management of patients with current or prior symptoms of HF and a reduced LVEF Diuretics and salt restriction for fluid retention. Angiotensin converting enzyme (ACE) inhibitors in all patients, unless contraindicated. Beta blockers in all stable patients, unless contraindicated. One of the three beta blockers proven to reduce mortality should be used (bisoprolol, carvedilol, and sustained release metoprolol succinate). Angiotensin II receptor blockers (ARBs) in patients who do not tolerate ACE inhibitors. Drugs that can adversely affect patient's clinical status should be avoided or withdrawn, if possible. These include NSAID drugs, most antiarrhythmic drugs, and most calcium channel blockers. Exercise training as an adjunctive approach to improve clinical status in ambulatory patients. An implantable cardioverter-defibrillator (ICD) for secondary prevention to prolong survival in patients with a history of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular tach An ICD for primary prevention to reduce total mortality by preventing sudden cardiac death (SCD) in patients with non-ischemic or ischemic heart disease who meet following criteria: at least 40 days post-MI, an LVEF 35 percent, NYHA functional class II or III symptoms despite optimal chronic medical therapy, and a reasonable expectation of survival with a good functional status for more than one year. Cardiac resynchronization therapy (CRT), with or without an ICD, unless contraindicated, in patients who meet: cardiac dyssynchrony ( QRS duration >120 msec) LVEF 35 percent, sinus rhythm, and NYHA functional class III or ambulatory class IV symptoms despite optimal medical therapy. Addition of an aldosterone antagonist is recommended in selected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal K concentration. Creatinine should be 2.5 mg per dL in men or 2.0 mg per dL in women and K should be <5.0 mEq per liter. Under circumstances in which monitoring for hyperkalemia and renal dysfunction is not anticipated to be feasible, risks may outweigh the benefits of aldosterone antagonists. Combination of hydralazine and nitrates recommended to improve outcomes for African-Americans, with moderate-severe symptoms on optimal therapy with ACE inhibitors, beta blockers, and diuretics. Class IIa - The weight of evidence and/or opinion is in favor of the following approaches being effective in the management of patients with current or prior symptoms of HF and a reduced LVEF It is reasonable to treat patients with atrial fibrillation and HF with a strategy to maintain sinus rhythm or with a strategy to control ventricular rate alone. Maximal exercise testing with or without measurement of respiratory gas exchange is reasonable to facilitate prescription of an appropriate exercise program for patients presenting with HF. ARBs as an alternative to ACE inhibitors as first-line therapy in patients with mild to moderate HF, particularly those already taking an ARB for other indications. Digitalis in patients with current or prior symptoms of HF to reduce hospitalization for HF. The addition of the combination of hydralazine and a nitrate in patients with persistent symptoms who are already

taking an ACE inhibitor and beta blocker. CRT with or without an ICD is reasonable in patients with an LVEF of 35 percent, a QRS 0.12 s econds, and atrial fibrillation who have New York Heart Association functional class III or ambulatory class IV symptoms symptoms despite optimal chronic medical therapy. CRT is reasonable in patients with an LVEF of 35 percent who have New York Heart Association functional class III or ambulatory class IV symptoms despite optimal medical therapy and who have frequent dependence of ventricular pacing. Class IIb - The weight of evidence and/or opinion is less well established for the following approaches in the management of patients with current or prior symptoms of HF and a reduced LVEF The combination of hydralazine and a nitrate in patients who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency. Addition of an ARB in patients with persistent symptoms who are already being treated with an ACE inhibitor, beta blocker, and diuretics. Class III - There is evidence and/or general agreement that the following approaches are not effective and may be harmful in the management of patients with current or prior symptoms of HF and a reduced LVEF Routine use of triple therapy with an ACE inhibitor, an ARB, and an aldosterone receptor antagonist is not recommended. Routine administration of calcium channel blockers are not indicated. Long-term infusion of a positive inotropic drug may be harmful and is not recommended, except as palliation for end-stage disease that cannot be stabilized with standard medical therapy. Nutritional supplements are not indicated. Hormonal therapies may be harmful and are not recommended unless given to replete hormone deficiencies.