Chronic heart failure stage functional classes

I50.0- Congestive heart failure

Currently, the following classifications are used in the Russian Federation: 1) Acute
heart failure (OSF) – the occurrence of acute (cardiogenic)
shortness of breath associated with the rapid development of congestion in the lungs (up to
before pulmonary edema) or cardiogenic shock, which are usually
a consequence of acute myocardial damage, especially acute heart attack
myocardium (AMI).

2) To determine the stage of heart failure use the classification of N.D. Strazhesko and V.X. Vasilenko (I-IV stage) (table. 2).

Table 2. Classification of chronic circulatory failure (N. D. Strazhesko, V. X. Vasilenko, 1935)

Description of the stage of the disease

Initial, latent circulatory failure, manifested
only during physical exertion (shortness of breath, palpitations, excessive
fatigue). At rest, these phenomena disappear. Hemodynamics not broken

Severe, prolonged circulatory failure, impaired
hemodynamics (congestion in the pulmonary and pulmonary circulation), disorders
functions of organs and metabolism are expressed and at rest, working capacity
sharply limited.

Hemodynamic impairment is moderate, impaired
functions of any part of the heart (right or left ventricular

Severe hemodynamic disturbances, involving all
cardiovascular system, severe hemodynamic disturbances in small and
big circle.

Ultimate, dystrophic. Severe circulatory failure,
persistent changes in metabolism and organ functions, irreversible
changes in the structure of organs and tissues, pronounced dystrophic
changes, complete disability.

3) To describe the severity of symptoms of heart failure, use the Functional Classification of the New York Heart Association (Table 3).

Table 3. Functional classification of chronic heart failure by the New York Heart Association

There are no restrictions on physical activity. Regular physical
activity does not cause excessive shortness of breath, fatigue or palpitations

A slight restriction in physical activity. Comfortable
a state at rest, but normal physical activity causes excessive
shortness of breath, fatigue, or palpitations

Explicit restriction of physical activity. Comfortable condition in
at rest, but less than usual physical activity causes excessive
shortness of breath, fatigue, or palpitations.

Inability to perform any physical activity without discomfort.
Symptoms may be present at rest. With any physical activity
discomfort intensifies

4) Depending on the state of myocardial contractility
the left ventricle, determined by the ejection fraction of the left ventricle (PV
LV) secrete: CHF with reduced LVEF (CHF-snFV, where LVEF is less than 40%),
CHF with intermediate LVEF (CHF-prFV, where LVEF is from 40 to 49%) and CHF with
normal LVEF (CHF-sFV, where LVEF is more than 50%) [35,36] (Table 4).

Table 4. Characteristics of chronic heart failure depending on the ejection fraction of the left ventricle

1. Increased levels of natriuretic peptides?

2. The presence of at least one of the additional criteria:

A) structural changes in the heart (LVH and/or ULP)

1. Increased levels of natriuretic peptides?

2. The presence of at least one of the additional criteria:

A) structural changes in the heart (LVH and/or ULP)

Note. LVH – left ventricular myocardial hypertrophy; ULP – an increase in the left atrium.

* – symptoms may be absent in the early stages of heart failure or
patients receiving diuretic therapy; ? -level of cerebral
natriuretic peptide (MNUP) gt; 35 pg/ml or N-terminal
prMNUPgt; 125 pg/ml.

In world practice, the most widespread classification of chronic heart failure is the New York Heart Association (NYHA), according to which four functional classes (FC) are distinguished.

  • FC1 (asymptomatic form) – fully compensated patients, without limiting normal physical activity, but having heart disease.
  • FCII (mild) is a slight limitation of physical activity. With the usual physical exertion for the patient, weakness, palpitations, shortness of breath occur. At rest, she feels good.
  • FCIII (moderate form) – a significant I restriction of physical activity. A small physical I load can lead to weakness, shortness of breath, etc.
  • FCIV (severe form) – HF symptoms exist at rest, and any physical activity increases discomfort.

In the CIS countries, the classification developed by N.D. Strazhesko and B.Kh. Vasilenko (1935), according to which four stages are distinguished.

  • I stage (initial) – only with physical exertion shortness of breath, fatigue, tachycardia are detected.
  • IIA stage – moderately severe hemodynamic disturbances, mainly of one circle of blood circulation.
  • IIB stage – deep hemodynamic disturbances in the large and small circle of blood circulation.
  • Stage III (dystrophic) – marked and persistent changes in hemodynamics, metabolism and irreversible structural disorders of various organs and tissues are noted.

The introduction of ultrasonic research methods allowed to supplement this classification with the allocation of the IA stage, which is called the early, or pre-stagnation. It is characterized by: violation of only diastolic function; the deterioration of myocardial contractile function, which occurs only during exercise, is manifested by an increase in filling pressure in the left ventricle, diastolic pressure in the pulmonary artery and a decrease in cardiac output by 10-20%.

Stage 1B of heart failure with this consideration corresponds to stage I of heart failure according to the classification of Strazhesko-Vasilenko.

In stage III of heart failure, it is also proposed to distinguish two periods:

  • period A (IIIA) is a partially irreversible stage, when against the background of adequate therapy, edema, anasarca, and stagnation phenomena of the left and right ventricular types are reduced,
  • and period B (IIIB) – a completely irreversible stage corresponding to stage III according to the classification of Strazhesko-Vasilenko.

“Functional classes and stages of chronic heart failure” – article from the section Cardiology

List of Abbreviations

AMKR – antagonists of mineralcorticoid receptors

BKK – calcium channel blockers

BLNPG – blockade of the left bundle branch block

BPNPG – blockade of the right bundle branch block

ARB – angiotensin II receptor blockers

BCC – sudden cardiac death

DDLH – LV diastolic dysfunction

SDS – diastolic heart failure

DKMP – dilated cardiomyopathy

VT – ventricular tachycardia

ZHNRS – ventricular arrhythmias

ACE inhibitors – angiotensin-converting enzyme inhibitors

IHD – coronary heart disease

ICD – implantable cardioverter defibrillator

INRA – Neprilizin/Angiotensin Receptor Inhibitors

ILI – artificial left ventricle

KTI – cardio-torocal index

KSh – coronary artery bypass grafting

LV – left ventricle

PLAIC – left ventricular cardiopulmonary bypass

LDL – low density lipoproteins

MKP – mineralocorticoid receptor

INR – international normalized attitude

IPC – mechanical support of blood circulation

MRI – magnetic resonance imaging

MSCT – multispiral computed tomography

NSAIDs – non-steroidal anti-inflammatory drugs

NUP – natriuretic peptide

AMI – acute myocardial infarction

RR – relative risk

OCH – acute heart failure

SPECT – single-photon emission computed tomography

PUFAs – Polyunsaturated Fatty Acids

PET – positron emission tomography

RAAS – renin – angiotensin – aldosterone system

RCTs – randomized controlled trials

RFA – Radio Frequency Ablation

GFR – glomerular filtration rate

Heart failure – heart failure

CPT – cardiac resynchronization therapy

SRT-D – cardiac resynchronization therapy-defibrillator

SRT-P – cardiac resynchronization therapy-pacemaker

TTG – thyroid-stimulating hormone

Feasibility study – thromboembolic complications

PV – ejection fraction

LVEF – left ventricular ejection fraction

AF – atrial fibrillation

COPD – chronic obstructive pulmonary disease

!  Cardiopulmonary failure causes, main symptoms, diagnosis

CHF – chronic heart failure

CHF-prFV – CH with intermediate LVEF

CHF-snFV – CH with reduced LVEF

CHF-sFV – CH with preserved LVEF

PCI – percutaneous coronary intervention

Heart rate – heart rate

ECMO – extracorporeal membrane oxygenation

BNP – cerebral natriuretic peptide

NT-pro BNP – N-terminal propeptide of natriuretic hormone (B-type)

NYHA – New York Heart Association

** – the drug is included in the list of vital and most important drugs

Terms and definitions

Heart failure
(CH) – according to one of the many definitions (2008), this
a condition associated with such a violation of the structure or function of the heart,
in which the satisfaction of myocardial oxygen demand is possible
only as a result of increased pressure filling the heart [1].

“Acute” CH (OCH) is a life-threatening condition,
characterized by rapid onset or sharp deterioration
symptoms/signs of heart failure up to the development of pulmonary edema or cardiogenic
shock requiring emergency medical measures and how
as a rule, quick hospitalization of the patient.

“Chronic” HF (CHF) – episodic, often gradual, intensification of symptoms/signs of HF is typical, up to the development of “decompensation”.

“Acute decompensation” of HF – a condition characterized by a pronounced exacerbation of symptoms/signs of heart failure.

“Systolic” CH – CH, characterized by a pronounced decrease in contractility of the left ventricle (LV).

“Diastolic” CH – CH, which is based on impaired LV relaxation function.

CHF with “preserved ejection fraction (LV) of LV” (CHF-sFV) – heart contractility in patients with heart failure is practically not impaired, LVEF? fifty%.

CHF with “reduced LVEF” (CHF-snFV) – CH, characterized by a pronounced decrease in LV contractility, LVEF is less than 40%.

CHF with “intermediate LVEF” (CHF-prFV) is characterized by a moderate decrease in LV contractility, LVEF = 40-49% (European Recommendations 2016).

The term “chronic circulatory failure”
(KNK) was introduced by A.L. Myasnikov, and is essentially a synonym for
“Chronic heart failure”, but was used only in
our country. To date, it is not recommended to replace the term

Heart failure is a clinical syndrome,
characterized by the presence of typical symptoms (shortness of breath, increased
fatigue, swelling of the legs and feet) and signs (increased pressure in
jugular veins, wheezing in the lungs, peripheral edema) caused by
violation of the structure and/or function of the heart, leading to a decrease
cardiac output and/or increased pressure filling the heart at rest
or under load.

Appendix B. Patient Information

  • Medical history and medical examination
  • Electrocardiogram (ECG)
  • Blood tests
  • Chest x-ray
  • Echo KG
  • Functional Pulmonary Tests
  • Load test
  • Magnetic resonance imaging of the heart (MRI)
  • Cardiac catheterization and angiography
  • Radioisotope studies
  • Multispiral computed tomography (MSCT)

Symptoms of each patient are individual, and depending on them may
Several of the above studies will be assigned.

1.2 Etiology and pathogenesis

There are a large number of etiological reasons for the development of heart failure.
(tab. 1). In Russia, the main causes of heart failure are arterial hypertension
(AH) and coronary heart disease (CHD) [2]. Their combination is found in
half of the patients [3]. Other causes of heart failure include various
heart defects (4,3%), myocarditis (3,6%) [3,4].

Approximately half of patients with heart failure have a reduced ejection fraction of the left
ventricle (CHF-snFV – chronic heart failure with reduced
left ventricular ejection fraction less than 40%), a smaller part –
normal (CHF-sFV – chronic heart failure with
stored ejection fraction? fifty%). Characteristics of a group of patients with
chronic heart failure with an intermediate ejection fraction
from 40 to 49% (CHF-prFV) are in an intermediate position between
CHF-snFV, and CHF-sFV, which requires additional studies
to complete the complete picture of the population of patients with heart failure [5].

Ischemic heart disease is
the cause of systolic heart failure in two-thirds of cases, often combined with
diabetes mellitus and arterial hypertension. From other reasons
systolic heart failure should be noted viral infections, abuse
alcohol, chemotherapy (doxorubicin or trastuzumab),
“Idiopathic” dilptational cardiomyopathy (DCMP) [3,4].

The epidemiology and etiology of CHF-sFV is different from systolic CHF.
Patients with CHF-sFV are older, among them there are more women and persons with obesity
[6,7]. They are less likely to have coronary heart disease, more often – arterial hypertension and
atrial fibrillation [3,8,9-13]. To rarer causes of CHF-sfv
include hypertrophic and restrictive cardiomyopathies,
constrictive pericarditis, hydropericardium, thyrotoxicosis, infiltrative
diseases, metastatic myocardial lesions and others.

In patients with systolic dysfunction of the left ventricle (LV)
changes in cardiomyocytes and extracellular matrix
after myocardial damage (e.g., myocardial infarction or
myocarditis), lead to pathological remodeling of the ventricle with its
dilatation, a change in geometry (LV becomes more spherical) and
breach of contractility.

Over time these changes
progress, although at the beginning of the disease, the symptoms of heart failure may not be
expressed. It is assumed that two are involved in this process.
pathophysiological mechanism. Firstly, new developments leading to
death of cardiomyocytes (for example, repeated myocardial infarction). However
further remodeling of the heart can occur in the absence of obvious
repeated myocardial damage.

Table 1 – Etiological causes of chronic heart failure

Diseases and forms

hypertrophic, dilated, restrictive cardiomyopathy, arrhythmogenic pancreatic dysplasia, non-compact LV myocardium

Myocarditis (inflammatory cardiomyopathy):

Infectious: viral, bacterial,

fungal, rickettsial, parasitic.

Immune: tetanus toxin, vaccines,

disease, giant cell myocarditis,

autoimmune diseases, sarcoidosis,

Toxic: chemotherapy, cocaine, alcohol, heavy metals (copper, iron, lead)

pheochromocytoma, deficiency of vitamins (e.g. thiamine), deficiency
selenium, carnitine, hypophosphatemia, hypokalemia, diabetes mellitus,

amyloidosis, malignant diseases

Valvular heart disease

Mitral, aortic, tricuspid, pulmonary

Constrictive pericarditis, hydropericardium

Congenital heart defects

Congenital heart defects

Tachyarrhythmias (atrial, ventricular)

Thyrotoxicosis, anemia, sepsis, thyrotoxicosis, Paget’s disease, arteriovenous fistula

Renal failure, iatrogenic

Secondly, a systemic response to a decrease in LV systolic function. At
patients there is an increase in the activity of pressor systems:
sympathoadrenal system (CAS), renin – angiotensin – aldosterone
systems (RAAS), endothelin, vasopressin and cytokine systems. Key
the activation of the renin-angiotensin-aldosterone system and
sympathetic nervous system.

These neurohumoral factors are not only
cause peripheral vasoconstriction, sodium and fluid retention, and,
therefore, an increase in hemodynamic load on the left ventricle, but also
have a direct toxic effect on the myocardium, stimulating fibrosis and
apoptosis, which leads to further remodeling of the heart and impaired
its function.

In addition to myocardial damage, activation
neurohumoral systems has an adverse effect on other
organs – blood vessels, kidneys, muscles, bone marrow, lungs and
the liver, forming a pathophysiological “vicious” circle and leading to many
clinical manifestations of heart failure, including electrical instability

Clinically, all these changes are associated with development and
the progression of symptoms of heart failure and lead to a deterioration in the quality of life,
decrease in physical activity of patients, decompensation of heart failure requiring
hospitalization, and to death as a result of “pumping” failure
heart, and the appearance of life-threatening ventricular arrhythmias.

It must be emphasized that the severity of symptoms of heart failure is far from always
correlates with LV ejection fraction (LVEF). It is the impact on these two
key processes (myocardial damage and neurohumoral activation
systems) underlies the treatment of heart failure. Heart reserve of such patients
also depends on atrial contraction, LV synchronism, and
interactions of the right ventricle (RV) and LV.

!  Mitral valve insufficiency grade 2 treatment prognosis

The pathophysiology of CHF-sFV, as already mentioned, has been studied much worse,
due to both the heterogeneity of this condition and the complexity
its diagnosis [11,12,16-19]. As a rule, the basis of such CH is
violation of the diastolic function of the left ventricle, i.e. his inability to
adequate filling without increasing the average pulmonary venous

LV diastolic function depends on both relaxation
myocardium, and from its mechanical properties. LV myocardial relaxation
is an active process that depends on the functioning
sarcoplasmic reticulum of cardiomyocytes. Active disorder
relaxation is one of the earliest manifestations of myocardial dysfunction
with most cardiovascular diseases [20,21].

The mechanical properties of the myocardium, which are characterized by
elasticity, suppleness and rigidity affect the filling of LV in phases
diastasis and atrial systole. Hypertrophy, fibrosis, or infiltration
myocardium increase its rigidity, which leads to a sharp increase
LV filling pressure. In addition, LV compliance also depends on the level of

LV compliance decreases with dilatation. IN
Three types are distinguished depending on the severity of diastolic disorders.
LV filling – delayed relaxation, pseudo-normalization and
restriction. The severity of clinical manifestations of diastolic heart failure and
the prognosis of patients is primarily determined by the severity of diastolic
dysfunction 22. The development of atrial fibrillation, tachycardia often
leads to decompensation of heart failure.

Until the 1990s, 60-70% of patients with heart failure died within 5 years.
Modern therapy has reduced the number of repeated
hospitalizations due to decompensation of heart failure, and mortality. Not
less, in Russia, the average annual mortality among patients with chronic heart failure I-IV FC
6%, and among patients with clinically severe heart failure – 12%

The prognosis of patients with CHF-sFV depends on the etiological cause of the disease
and the severity of diastolic dysfunction, but usually
more favorable than the prognosis of patients with CHF-snFV [24,25,28-31].

Appendix A2. Clinical Guidelines Development Methodology

  • A physical examination is recommended to identify
    symptoms and clinical signs due to sodium retention and

In some cases, due to the clinical situation, additional
research methods, complementing each other, help in differential
diagnosis of various cardiovascular diseases. Selection of each of
They are due to diagnostic capabilities and the risk of side effects.

  • Recommended coronary angiography in patients with the clinic
    angina pectoris are potential candidates for revascularization
    myocardium 70.
  • A radionuclide diagnosis is recommended, including
    single-photon emission computed tomography and radionuclide
    ventriculography, to assess ischemia and determine viability
    myocardium in patients with coronary heart disease [71].

Level of credibility of recommendations IIb (Level of evidence confidence C).

  • Cardiac catheterization is recommended for evaluating left and right function.
    departments of the heart, pressure jamming in the pulmonary artery when solving
    heart transplant or mechanical support.
  • Conducting exercise tests is recommended to assess the functional status and effectiveness of treatment.

The level of credibility of recommendations IIa (The level of reliability of evidence C).

  • Transesophageal echocardiography (PE EchoCG) is recommended in routine
    practice in patients with heart failure in cases of poor visualization (in patients with
    obesity, chronic lung disease, when performed in patients
    ventilation) and as an alternative research method
    (if it is impossible to have an MRI).

Level of credibility of recommendations IIa (Level of evidence confidence C).

Description of methods used to collect/select evidence: evidence-based
The basis for recommendations are publications included in the Cochrane
library, EMBASE and MEDLINE databases. Search Depth was 5

Methods used to assess the quality and strength of evidence: expert consensus.

Priorities for the use of drug therapy were set to
Based on evidence-based medicine results. In the absence of high data
the reliability took into account the agreed opinion of experts.

Procedure for updating recommendations

The revision of the existing version of the recommendations is planned to be carried out every 3 years.

Classes of recommendations and levels of evidence

Management classes and evidence levels for patient management
based on documents from the European Society of Cardiology (ЕОК, European
Society of Cardiology), 2012-2016. (see Appendix 1 and 2)

Appendix P1. Level of credibility of recommendations

Evidence and/or general agreement that the proposed treatment/effect is successful, beneficial, and effective in all patients

Conflicting or controversial evidence that the proposed treatment/effect is successful and beneficial (in most patients)

The weight of evidence/points of view on the benefits (effectiveness) of the proposed treatment/exposure prevails

Application should be considered

Evidence of Benefit (Efficiency)

proposed treatment/effects are less obvious

Application may be considered

Available evidence/expert opinion suggests that treatment
useless/ineffective, and in some cases can be harmful

Appendix P2. Evidence confidence level

Data derived from several randomized trials or meta-analyzes.

Data from one randomized or multiple non-randomized large trials

Consistent expert opinion and/or results of small studies, retrospective studies, registers

Last Clinical Guidelines Revision Approved by National
Society for the Study of Heart Failure and Myocardial Disease 7
October 2016, at the I Russian Forum on Heart Failure and
myocardial diseases, Ufa.

Target audience of these clinical recommendations:

  1. Cardiologist.
  2. General practitioner.
  3. General doctor.

2.3 Laboratory Diagnostics

  • To verify the diagnosis of heart failure, all patients are recommended to determine the level of natriuretic hormones.

Commodities: natriuretic hormones –
biological markers of heart failure, the indicators of which are also used for
monitoring the effectiveness of treatment. Normal level of natriuretic
hormones in untreated patients practically eliminates the defeat
heart, which makes the diagnosis of heart failure unlikely. N-terminal levels
B-type natriuretic hormone propeptide (NT-proBNP) lt;

  • All patients are recommended to verify the diagnosis of heart failure.
    routine tests: general blood count (exclusion of anemia, assessment
    platelet count, white blood cell count), determination of electrolyte levels (potassium,
    sodium), creatinine and glomerular filtration rate (estimated
    indicator), glucose, HbA1c, lipid profile and liver enzymes,
    general (clinical) urinalysis.

2.4 Instrumental diagnostics

Instrumental diagnostic methods such as electrocardiography
(ECG), echocardiocgaphia (echocardiography) play a key role in confirming
diagnosis of heart failure.

  • All patients are recommended to verify the diagnosis of heart failure.
    12-channel ECG with heart rate, heart rate
    contractions (heart rate), morphology and duration of QRS, the presence of violations
    AV and ventricular conduction (blockade of the left leg of the bundle of His (BLNPG),
    blockade of the right bundle branch block (BPNPG)), cicatricial myocardial damage,
    myocardial hypertrophy) 50.

Level of evidence of recommendations I (Level of evidence evidence C.

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Editor-in-chief of the Detonic online magazine, cardiologist Yakovenko-Plahotnaya Tatyana. Author of more than 950 scientific articles, including in foreign medical journals. He has been working as a cardiologist in a clinical hospital for over 12 years. He owns modern methods of diagnosis and treatment of cardiovascular diseases and implements them in his professional activities. For example, it uses methods of resuscitation of the heart, decoding of ECG, functional tests, cyclic ergometry and knows echocardiography very well.

For 10 years, she has been an active participant in numerous medical symposia and workshops for doctors - families, therapists and cardiologists. He has many publications on a healthy lifestyle, diagnosis and treatment of heart and vascular diseases.

He regularly monitors new publications of European and American cardiology journals, writes scientific articles, prepares reports at scientific conferences and participates in European cardiology congresses.