Stage A identifies patients at high risk for heart failure because of conditions such as hypertension, diabetes, and obesity.
• Treat each comorbidity according to current evidence-based guidelines.
Stage B includes patients with structural heart disease, such as left ventricular remodeling, left ventricular hypertrophy, or previous MI, but no symptoms.
• Provide all appropriate therapies in Stage A.
• Focus on slowing the progression of ventricular remodeling and delaying the onset of heart failure symptoms.
• Strongly recommended in appropriate patients: Treat with ACE inhibitors or beta-blockers unless contraindicated; these drugs delay the onset of symptoms and decrease the risk of death and hospitalization.
Stage C includes patients with past or current heart failure symptoms associated with structural heart disease such as advanced ventricular remodeling.
• Use appropriate treatments for Stages A and B.
• Modify fluid and dietary intake.
• Use additional drug therapies, such as diuretics, aldosterone inhibitors, and ARBs in patients who can’t tolerate ACE inhibitors, digoxin, and vasodilators.
• Treat with nonpharmacologic measures such as biventricular pacing, an ICD, and valve or revascularization surgery.
• Avoid drugs known to cause adverse reactions in symptomatic patients, including nonsteroidal anti-inflammatory drugs, most antiarrhythmics, and calcium channel blockers.
• Administer anticoagulation therapy to patients with a history of previous embolic event, paroxysmal or persistent atrial fibrillation, familial dilated cardiomyopathy, and underlying disorders that may increase the risk of thromboembolism.
Stage D includes patients with refractory advanced heart failure having symptoms at rest or with minimal exertion and frequently requiring intervention in the acute setting because of clinical deterioration.
• Improve cardiac performance.
• Facilitate diuresis.
• Promote clinical stability.
Achieving these goals may require I.V. diuretics, inotropic support (milrinone, dobutamine, or dopamine), or vasodilators (nitroprusside, nitroglycerin, or nesiritide). As heart failure progresses, many patients can no longer tolerate ACE inhibitors and beta-blockers due to renal dysfunction and hypotension and may need supportive therapy to sustain life (a left ventricular assist device, continuous I.V. inotropic therapy, experimental surgery or drugs, or a heart transplant) or end-of-life or hospice care.