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Class I symptoms of HF only at activity levels that would limit normal individuals
Class II symptoms of HF with ordinary exertion
Class III symptoms of HF with less than ordinary exertion
Class IV symptoms of HF at rest
Stages in the development of HF There are several stages in the evolution of HF, as outlined
by the American College of Cardiology/American Heart Association (ACC/AHA) guidelines [2]:
Stage A High risk for HF, without structural heart disease or symptoms
This staged system, in contrast to the NYHA classification, emphasizes the progressive nature of
HF and defines the appropriate therapeutic approach for each stage.
The long-term prognosis can also be estimated. The peak VO2 is the most accurate predictor of
prognosis, but functional class and exercise capacity, the magnitude of the reduction in ejection
fraction with systolic dysfunction, serum BNP concentrations, and a variety of other factors are
also important. (See "Predictors of survival in heart failure due to systolic dysfunction" and
"Prognosis of heart failure", section on 'Predictive models'.)
Etiology There are two basic pathophysiologic mechanisms that cause reduced cardiac output
and HF: systolic dysfunction and diastolic dysfunction. Systolic and diastolic dysfunction each
may be due to a variety of etiologies. Effective management is often dependent upon establishing
the correct etiologic diagnosis. As an example, coronary revascularization may be beneficial in
patients with ischemic cardiomyopathy who have evidence of hibernating myocardium (see
'Detection of coronary artery disease' below).
Systolic dysfunction The most common causes of systolic dysfunction are coronary
(ischemic) heart disease, idiopathic dilated cardiomyopathy (DCM), hypertension, and valvular
disease. Effective therapy of hypertension has led to a changing pattern in which coronary
disease has become more prevalent as a cause of HF [3,4]. In one review, coronary disease and
hypertension accounted for 62 and 10 percent of cases, respectively [3]. (See "Epidemiology and
causes of heart failure".)