HomeCirculationVol. 128, No. 162013 ACCF/AHA Guideline for the Management of Heart Failure: Executive Summary Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUB2013 ACCF/AHA Guideline for the Management of Heart Failure: Executive SummaryA Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Clyde W. Yancy, MD, MSc, FACC, FAHA, Chair, Mariell Jessup, MD, FACC, FAHA, Vice Chair, Biykem Bozkurt, MD, PhD, FACC, FAHA, Javed Butler, MBBS, FACC, FAHA, Donald E. CaseyJr, MD, MPH, MBA, FACP, FAHA, Mark H. Drazner, MD, MSc, FACC, FAHA, Gregg C. Fonarow, MD, FACC, FAHA, Stephen A. Geraci, MD, FACC, FAHA, FCCP, Tamara Horwich, MD, FACC, James L. Januzzi, MD, FACC, Maryl R. Johnson, MD, FACC, FAHA, Edward K. Kasper, MD, FACC, FAHA, Wayne C. Levy, MD, FACC, Frederick A. Masoudi, MD, MSPH, FACC, FAHA, Patrick E. McBride, MD, MPH, FACC, John J.V. McMurray, MD, FACC, Judith E. Mitchell, MD, FACC, FAHA, Pamela N. Peterson, MD, MSPH, FACC, FAHA, Barbara Riegel, DNSc, RN, FAHA, Flora Sam, MD, FACC, FAHA, Lynne W. Stevenson, MD, FACC, W.H. Wilson Tang, MD, FACC, Emily J. Tsai, MD, FACC and Bruce L. Wilkoff, MD, FACC, FHRS Clyde W. YancyClyde W. Yancy Search for more papers by this author , Mariell JessupMariell Jessup Search for more papers by this author , Biykem BozkurtBiykem Bozkurt Search for more papers by this author , Javed ButlerJaved Butler Search for more papers by this author , Donald E. CaseyJrDonald E. CaseyJr Search for more papers by this author , Mark H. DraznerMark H. Drazner Search for more papers by this author , Gregg C. FonarowGregg C. Fonarow Search for more papers by this author , Stephen A. GeraciStephen A. Geraci Search for more papers by this author , Tamara HorwichTamara Horwich Search for more papers by this author , James L. JanuzziJames L. Januzzi Search for more papers by this author , Maryl R. JohnsonMaryl R. Johnson Search for more papers by this author , Edward K. KasperEdward K. Kasper Search for more papers by this author , Wayne C. LevyWayne C. Levy Search for more papers by this author , Frederick A. MasoudiFrederick A. Masoudi Search for more papers by this author , Patrick E. McBridePatrick E. McBride Search for more papers by this author , John J.V. McMurrayJohn J.V. McMurray Search for more papers by this author , Judith E. MitchellJudith E. Mitchell Search for more papers by this author , Pamela N. PetersonPamela N. Peterson Search for more papers by this author , Barbara RiegelBarbara Riegel Search for more papers by this author , Flora SamFlora Sam Search for more papers by this author , Lynne W. StevensonLynne W. Stevenson Search for more papers by this author , W.H. Wilson TangW.H. Wilson Tang Search for more papers by this author , Emily J. TsaiEmily J. Tsai Search for more papers by this author and Bruce L. WilkoffBruce L. Wilkoff Search for more papers by this author Originally published5 Jun 2013https://doi.org/10.1161/CIR.0b013e31829e8807Circulation. 2013;128:1810–1852Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 Table of ContentsPreamble 18111. Introduction 18141.1. Methodology and Evidence Review 18141.2. Organization of the Writing Committee 18141.3. Document Review and Approval 18141.4. Scope of This Guideline With Reference to Other Relevant Guidelines or Statements 18142. Definition of HF 18143. HF Classifications 18164. Epidemiology 18165. Initial and Serial Evaluation of the HF Patient: Recommendations 18175.1. Clinical Evaluation 18175.1.1. History and Physical Examination 18175.1.2. Risk Scoring 18175.2. Diagnostic Tests 18175.3. Biomarkers 18185.4. Noninvasive Cardiac Imaging 18185.5. Invasive Evaluation 18196. Treatment of Stages A to D: Recommendations 18206.1. Stage A 18206.2. Stage B 18206.3. Stage C 18216.3.1. Nonpharmacological Interventions 18216.3.2. Pharmacological Treatment for Stage C HFrEF 18216.3.3. Pharmacological Treatment for Stage C HFpEF 18246.3.4. Device Therapy for Stage C HFrEF 18266.4. Stage D18286.4.1. Water Restriction 18296.4.2. Inotropic Support 18296.4.3. Mechanical Circulatory Support 18306.4.4. Cardiac Transplantation 18307. The Hospitalized Patient: Recommendations 18317.1. Precipitating Causes of Decompensated HF 18317.2. Maintenance of GDMT During Hospitalization 18317.3. Diuretics in Hospitalized Patients 18327.4. Renal Replacement Therapy—Ultrafiltration 18327.5. Parenteral Therapy in Hospitalized HF 18337.6. Venous Thromboembolism Prophylaxis in Hospitalized Patients 18337.7. Arginine Vasopressin Antagonists 18337.8. Inpatient and Transitions of Care 18338. Important Comorbidities in HF 18349. Surgical/Percutaneous/Transcatheter Interventional Treatments of HF: Recommendations 183410. Coordinating Care for Patients With Chronic HF: Recommendations 183511. Quality Metrics/Performance Measures: Recommendations 183512. Evidence Gaps and Future Research Directions1835References 1837Appendix 1. Author Relationships With Industry and Other Entities (Relevant) 1846Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) 1849PreambleThe medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist clinicians in selecting the best management strategy for an individual patient. Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools.The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly produced guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines (Task Force), charged with developing, updating, and revising practice guidelines for cardiovascular diseases and procedures, directs and oversees this effort. Writing committees are charged with regularly reviewing and evaluating all available evidence to develop balanced, patient-centric recommendations for clinical practice.Experts in the subject under consideration are selected by the ACCF and AHA to examine subject-specific data and write guidelines in partnership with representatives from other medical organizations and specialty groups. Writing committees are asked to perform a literature review; weigh the strength of evidence for or against particular tests, treatments, or procedures; and include estimates of expected outcomes where such data exist. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered. When available, information from studies on cost is considered, but data on efficacy and outcomes constitute the primary basis for the recommendations contained herein.In analyzing the data and developing recommendations and supporting text, the writing committee uses evidence-based methodologies developed by the Task Force.1 The Class of Recommendation (COR) is an estimate of the size of the treatment effect considering risks versus benefits in addition to evidence and/or agreement that a given treatment or procedure is or is not useful/effective or in some situations may cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing committee reviews and ranks evidence supporting each recommendation with the weight of evidence ranked as LOE A, B, or C according to specific definitions that are included in Table 1. Studies are identified as observational, retrospective, prospective, or randomized where appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues for which sparse data are available, a survey of current practice among the clinicians on the writing committee is the basis for LOE C recommendations and no references are cited. The schema for COR and LOE are summarized in Table 1, which also provides suggested phrases for writing recommendations within each COR. A new addition to this methodology is separation of the Class III recommendations to delineate whether the recommendation is determined to be of “no benefit” or is associated with “harm” to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another have been added for COR I and IIa, LOE A or B only.Table 1. Applying Classification of Recommendation and Level of EvidenceTable 1. Applying Classification of Recommendation and Level of EvidenceIn view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACCF/AHA guideline−recommended therapies (primarily Class I). This new term, GDMT, will be used herein and throughout all future guidelines.Because the ACCF/AHA practice guidelines address patient populations (and clinicians) residing in North America, drugs that are not currently available in North America are discussed in the text without a specific COR. For studies performed in large numbers of subjects outside North America, each writing committee reviews the potential influence of different practice patterns and patient populations on the treatment effect and relevance to the ACCF/AHA target population to determine whether the findings should inform a specific recommendation.The ACCF/AHA practice guidelines are intended to assist clinicians in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding care of a particular patient must be made by the clinician and patient in light of all the circumstances presented by that patient. As a result, situations may arise for which deviations from these guidelines may be appropriate. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas will be identified within each respective guideline when appropriate.Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Because lack of patient understanding and adherence may adversely affect outcomes, clinicians should make every effort to engage the patient’s active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment and be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, for which the benefit-to-risk ratio may be lower.The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the members of the writing committee. All writing committee members and peer reviewers of the guideline are required to disclose all current healthcare-related relationships, including those existing 12 months before initiation of the writing effort. In December 2009, the ACCF and AHA implemented a new policy for relationship with industry and other entities (RWI) that requires the writing committee chair plus a minimum of 50% of the writing committee to have no relevant RWI (Appendix 1 includes the ACCF/AHA definition of relevance). These statements are reviewed by the Task Force and all members during each conference call and/or meeting of the writing committee and are updated as changes occur. All guideline recommendations require a confidential vote by the writing committee and must be approved by a consensus of the voting members. Members are not permitted to draft or vote on any text or recommendations pertaining to their RWI. Members who recused themselves from voting are indicated in the list of writing committee members, and specific section recusals are noted in Appendix 1. Authors’ and peer reviewers’ RWI pertinent to this guideline are disclosed in Appendixes 1 and 2, respectively. Additionally, to ensure complete transparency, writing committee members’ comprehensive disclosure information—including RWI not pertinent to this document—is available as an online supplement. Comprehensive disclosure information for the Task Force is also available online at http://www.cardiosource.org/en/ACC/About-ACC/Who-We-Are/Leadership/Guidelines-and-Documents-Task-Forces.aspx. The work of writing committees is supported exclusively by the ACCF and AHA without commercial support. Writing committee members volunteered their time for this activity.In an effort to maintain relevance at the point of care for practicing clinicians, the Task Force continues to oversee an ongoing process improvement initiative. As a result, in response to pilot projects, several changes to these guidelines will be apparent, including limited narrative text, a focus on summary and evidence tables (with references linked to abstracts in PubMed), and more liberal use of summary recommendation tables (with references that support LOE) to serve as a quick reference.In April 2011, the Institute of Medicine released 2 reports: Clinical Practice Guidelines We Can Trust and Finding What Works in Health Care: Standards for Systematic Reviews.2,3 It is noteworthy that the ACCF/AHA practice guidelines are cited as being compliant with many of the proposed standards. A thorough review of these reports and of our current methodology is under way, with further enhancements anticipated.The recommendations in this guideline are considered current until they are superseded by a focused update or the full-text guideline is revised. Guidelines are official policy of both the ACCF and AHA. The reader is encouraged to consult the full-text guideline4 for additional guidance and details about heart failure, because the Executive Summary contains only the recommendations.Jeffrey L. Anderson, MD, FACC, FAHAChair, ACCF/AHA Task Force on Practice Guidelines1. Introduction1.1. Methodology and Evidence ReviewThe recommendations listed in this document are, whenever possible, evidence based. An extensive evidence review was conducted through October 2011 and includes selected other references through April 2013. The relevant data are included in evidence tables in the Data Supplement. Searches were extended to studies, reviews, and other evidence conducted in human subjects and that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected databases relevant to this guideline. Key search words included but were not limited to the following: heart failure, cardiomyopathy, quality of life, mortality, hospitalizations, prevention, biomarkers, hypertension, dyslipidemia, imaging, cardiac catheterization, endomyocardial biopsy, angiotensin-converting enzyme inhibitors, angiotensin-receptor antagonists/blockers, beta blockers, cardiac, cardiac resynchronization therapy, defibrillator, device-based therapy, implantable cardioverter-defibrillator, device implantation, medical therapy, acute decompensated heart failure, preserved ejection fraction, terminal care and transplantation, quality measures, and performance measures. Additionally, the committee reviewed documents related to the subject matter previously published by the ACCF and AHA. References selected and published in this document are representative and not all-inclusive.1.2. Organization of the Writing CommitteeThe committee was composed of physicians and a nurse with broad expertise in the evaluation, care, and management of patients with heart failure (HF). The authors included general cardiologists, HF and transplant specialists, electrophysiologists, general internists, and physicians with methodological expertise. The committee included representatives from the ACCF, AHA, American Academy of Family Physicians, American College of Chest Physicians, American College of Physicians, Heart Rhythm Society, and International Society for Heart and Lung Transplantation.1.3. Document Review and ApprovalThis document was reviewed by 2 official reviewers each nominated by both the ACCF and the AHA, as well as 1 to 2 reviewers each from the American Academy of Family Physicians, American College of Chest Physicians, Heart Rhythm Society, and International Society for Heart and Lung Transplantation, as well as 32 individual content reviewers (including members of the ACCF Adult Congenital and Pediatric Cardiology Council, ACCF Cardiovascular Team Council, ACCF Council on Cardiovascular Care for Older Adults, ACCF Electrophysiology Committee, ACCF Heart Failure and Transplant Council, ACCF Imaging Council, ACCF Prevention Committee, ACCF Surgeons’ Scientific Council, and ACCF Task Force on Appropriate Use Criteria). All information on reviewers’ RWI was distributed to the writing committee and is published in this document (Appendix 2).This document was approved for publication by the governing bodies of the ACCF and AHA and endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American College of Chest Physicians, Heart Rhythm Society, and International Society for Heart and Lung Transplantation.1.4. Scope of This Guideline With Reference to Other Relevant Guidelines or StatementsThis guideline covers multiple management issues for the adult patient with HF. Although there is an abundance of evidence addressing HF, for many important clinical considerations, this writing committee was unable to identify sufficient data to properly inform a recommendation. The writing committee actively worked to reduce the number of LOE “C” recommendations, especially for Class I−recommended therapies. Despite these limitations, it is apparent that much can be done for HF. Adherence to the clinical practice guidelines herein reproduced should lead to improved patient outcomes.Although of increasing importance, children with HF and adults with congenital heart lesions are not specifically addressed in this guideline. The reader is referred to publically available resources to address questions in these areas. However, this guideline does address HF with preserved ejection fraction (EF) in more detail and similarly revisits hospitalized HF. Additional areas of renewed interest are stage D HF, palliative care, transition of care, and quality of care for HF. Certain management strategies appropriate for the patient at risk for HF or already affected by HF are also reviewed in numerous relevant clinical practice guidelines and scientific statements published by the ACCF/AHA Task Force on Practice Guidelines, AHA, ACCF Task Force on Appropriate Use Criteria, European Society of Cardiology, Heart Failure Society of America, and the National Heart, Lung, and Blood Institute. The writing committee saw no need to reiterate the recommendations contained in those guidelines and chose to harmonize recommendations when appropriate and eliminate discrepancies. This is especially the case for device-based therapeutics, where complete alignment between the HF guideline and the device-based therapy guideline was deemed imperative.5 Some recommendations from earlier guidelines have been updated as warranted by new evidence or a better understanding of earlier evidence, whereas others that were no longer accurate or relevant or that were overlapping were modified; recommendations from previous guidelines that were similar or redundant were eliminated or consolidated when possible.The present document recommends a combination of lifestyle modifications and medications that constitute GDMT. GDMT is specifically referenced in the recommendations for treatment of HF (Section 6.3.2). Both for GDMT and other recommended drug treatment regimens, the reader is advised to confirm dosages with product insert material and to evaluate carefully for contraindications and drug-drug interactions. Table 2 is a list of documents deemed pertinent to this effort and is intended for use as a resource; it obviates the need to repeat already extant guideline recommendations. Additional other HF guideline statements are highlighted as well for the purpose of comparison and completeness.Table 2. Associated Guidelines and StatementsTitleOrganizationPublication Year (Reference)Guidelines Guidelines for the Management of Adults With Congenital Heart DiseaseACCF/AHA20086 Guidelines for the Management of Patients With Atrial FibrillationACCF/AHA/HRS20117–9 Guideline for Assessment of Cardiovascular Risk in Asymptomatic AdultsACCF/AHA201010 Guideline for Coronary Artery Bypass Graft SurgeryACCF/AHA201111 Guidelines for Device-Based Therapy of Cardiac Rhythm AbnormalitiesACCF/AHA/HRS20135 Guideline for the Diagnosis and Treatment of Hypertrophic CardiomyopathyACCF/AHA201112 Guideline for Percutaneous Coronary InterventionACCF/AHA/SCAI201113 Secondary Prevention and Risk Reduction Therapy for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2011 UpdateAHA/ACCF201114 Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart DiseaseACCF/AHA/ACP/AATS/PCNA/SCAI/STS201215 Guideline for the Management of ST-Elevation Myocardial InfarctionACCF/AHA201316 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial InfarctionACCF/AHA201317 Guidelines for the Management of Patients With Valvular Heart DiseaseACCF/AHA200818 Comprehensive Heart Failure Practice GuidelineHFSA201019 Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart FailureESC201220 Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary CareNICE201021 Antithrombotic Therapy and Prevention of ThrombosisACCP201222 Guidelines for the Care of Heart Transplant RecipientsISHLT201023Statements Contemporary Definitions and Classification of the CardiomyopathiesAHA200624 Genetics and Cardiovascular DiseaseAHA201225 Appropriate Utilization of Cardiovascular Imaging in Heart FailureACCF201326 Appropriate Use Criteria for Coronary Revascularization Focused UpdateACCF201227 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood PressureNHLBI200328 Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III GuidelinesNHLBI200229 Referral, Enrollment, and Delivery of Cardiac Rehabilitation/Secondary Prevention Programs at Clinical Centers and BeyondAHA/AACVPR201130 Decision Making in Advanced Heart FailureAHA201231 Recommendations for the Use of Mechanical Circulatory Support: Device Strategies and Patient SelectionAHA201232 Advanced Chronic Heart FailureESC200733 Oral Antithrombotic Agents for the Prevention of Stroke in Nonvalvular Atrial FibrillationAHA/ASA201234 Third Universal Definition of Myocardial InfarctionESC/ACCF/AHA/WHF201235AACVPR indicates American Association of Cardiovascular and Pulmonary Rehabilitation; AATS, American Association for Thoracic Surgery; ACCF, American College of Cardiology Foundation; ACCP, American College of Chest Physicians; ACP, American College of Physicians; AHA, American Heart Association; ASA, American Stroke Association; ESC, European Society of Cardiology; HFSA, Heart Failure Society of America; HRS, Heart Rhythm Society; ISHLT, International Society for Heart and Lung Transplantation; NHLBI, National Heart, Lung, and Blood Institute; NICE, National Institute for Health and Clinical Excellence; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Angiography and Interventions; STS, Society of Thoracic Surgeons; and WHF, World Heart Federation.2. Definition of HFHF is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood. The cardinal manifestations of HF are dyspnea and fatigue, which may limit exercise tolerance, and fluid retention, which may lead to pulmonary and/or splanchnic congestion and/or peripheral edema. Some patients have exercise intolerance but little evidence of fluid retention, whereas others complain primarily of edema, dyspnea, or fatigue. Because some patients present without signs or symptoms of volume overload, the term “heart failure” is preferred over “congestive heart failure.” There is no single diagnostic test for HF because it is largely a clinical diagnosis based on a careful history and physical examination.The clinical syndrome of HF may result from disorders of the pericardium, myocardium, endocardium, heart valves, or great vessels, or from certain metabolic abnormalities, but most patients with HF have symptoms due to impaired left ventricular (LV) myocardial function. It should be emphasized that HF is not synonymous with either cardiomyopathy or LV dysfunction; these latter terms describe possible structural or functional reasons for the development of HF. HF may be associated with a wide spectrum of LV functional abnormalities, which may range from patients with normal LV size and preserved EF to those with severe dilatation and/or markedly reduced EF. In most patients, abnormalities of systolic and diastolic dysfunction coexist, irrespective of EF. EF is considered important in classification of patients with HF because of differing patient demographics, comorbid conditions, prognosis, and response to therapies36 and because most clinical trials selected patients based on EF. EF values are dependent on the imaging technique used, method of analysis, and operator. As other techniques may indicate abnormalities in systolic function among patients with a preserved EF, it is preferable to use the terms preserved or reduced EF over preserved or reduced systolic function. For the remainder of this guideline, we will consistently refer to HF with preserved EF and HF with reduced EF as HFpEF and HFrEF, respectively (Table 3).Table 3. Definitions of HFrEF and HFpEFClassificationEF (%)DescriptionI. Heart failure with reduced ejection fraction (HFrEF)≤40Also referred to as systolic HF. Randomized controlled trials have mainly enrolled patients with HFrEF, and it is only in these patients that efficacious therapies have been demonstrated to date.II. Heart failure with preserved ejection fraction (HFpEF)≥50Also referred to as diastolic HF. Several different criteria have been used to further define HFpEF. The diagnosis of HFpEF is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF. To date, efficacious therapies have not been identified. a. HFpEF, borderline41 to 49These patients fall into a borderline or intermediate group. Their characteristics, treatment patterns, and outcomes appear similar to those of patients with HFpEF. b. HFpEF, improved>40It has been recognized that a subset of patients with HFpEF previously had HFrEF. These patients with improvement or recovery in EF may be clinically distinct from those with persistently preserved or reduced EF. Further research is needed to better characterize these patients.EF indicates ejection fraction; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; and HFrEF, heart failure with reduced ejection fraction3. HF ClassificationsBoth the ACCF/AHA stages of HF37 and the New York Heart Association (NYHA) functional classification37,38 provide useful and complementary information about the presence and severity of HF. The ACCF/AHA stages of HF emphasize the development and progression of disease and can be used to describe individuals and populations, whereas the NYHA classes focus on exercise capacity and the symptomatic status of the disease (Table 4).Table 4. Comparison of ACCF/AHA Stages of HF and NYHA Functional ClassificationsACCF/AHA Stages of HF37NYHA Functional Classification38AAt high risk for HF but without structural heart disease or symptoms of HFNoneBStructural heart disease but without signs or symptoms of HFINo limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.CStructural heart disease with prior or current symptoms of HFINo limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.IISlight limitation of physical activity. Comfortable at rest, but ordinary physical