Healthcare provider in clinic discussing the 4 stages of congestive heart failure

What Are the 4 Stages of Congestive Heart Failure?

Medically reviewed on Feb 25, 2024 by Jordan Stachel, M.S., RDN, CPT. To give you technically accurate, evidence-based information, content published on the Everlywell blog is reviewed by credentialed professionals with expertise in medical and bioscience fields.

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The Centers for Disease Control (CDC) estimates some 6.2 million American adults have heart failure—though congestive heart failure is a bit different. [1]

Healthcare providers may use the term “heart failure” when the heart cannot adequately conduct blood flow to support the body. But congestive heart failure (CHF) is a progressive condition that causes a buildup of fluid, resulting in escalating physical damage and, if improperly managed, death. [2]

Fortunately, definitions and classification systems for CHF have evolved to allow more patients to receive heart failure treatment early and improve their long-term health outcomes. [3] Many wonder, what are the 4 stages of congestive heart failure?

If you’ve been diagnosed with one of the four stages of CHF, understanding how they compare is fundamental for establishing the most effective treatment in your healing.

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Understanding Congestive Heart Failure and Its Classifications

Congestive heart failure is not a disease but a cluster of symptoms that characterize cardiac dysfunction or structural damage. [4]

People who may be at high risk for CHF typically exhibit at least one of the following biomarkers [4]:

  • Elevated natriuretic peptide levels, which are hormones that the heart releases when it’s stretched or enlarged. This can occur in CHF due to excessive stress, like pressure and fluid volume. [5]
  • Evidence of buildup in the body, especially in the lungs and heart.

In 2020, an assembly of healthcare professionals agreed upon what’s known as the Universal Definition and Classification of Heart Failure to define this condition better and to improve patient outcomes. [3] Because of the high degree of variance in CHF symptoms, the condition is largely graded by patient mortality risk.

In total, there are 4 stages of congestive heart failure:

  • Stage A: At Risk of Heart Failure
  • Stage B: Pre-Heart Failure
  • Stage C: Heart Failure
  • Stage D: Advanced Heart Failure

Whether you’re at stage A or D of CHF, it’s important to understand that all four stages are progressive: without proper management and lifestyle changes, even stages that don’t present with symptoms can worsen over time. This can result in a much lower quality of life, high healthcare costs, and even fatality.

With that said, it’s important to take any CHF diagnosis seriously. Knowing what makes each stage distinct can help you gain a clearer picture of your treatment options and allow you to feel motivated to be proactive about your health.

Stage A: At Risk for Heart Failure

If you're diagnosed with Stage A congestive heart failure, you won’t experience any cardiac or pulmonary symptoms or structural abnormalities impacting the heart.

Instead, you may have other diagnosed health conditions or considerations that could put you at risk, including [6]:

  • Diabetes
  • Hypertension
  • Metabolic syndrome
  • Using cardiotoxic medication
  • A genetic predisposition for cardiomyopathy, a condition that makes it more difficult for the heart to distribute blood to other parts of your body [7]

Treating any associated conditions in cooperation with your healthcare provider can greatly improve outcomes for Stage A congestive heart failure.

For instance, if you’ve been diagnosed with diabetes, be sure to monitor your blood glucose levels and to take any medication you’ve been prescribed regularly. Adopting new lifestyle habits (these can be found below) may also significantly improve outcomes for conditions like hypertension and metabolic syndrome.

Stage B: Pre-Heart Failure

Pre-heart failure is also asymptomatic: it does not present with symptoms of heart failure. [8] However, it can be associated with structural damage or signs of added pressure to the heart. [6] You may also [8]:

  • Have already been diagnosed with heart disease [9]
  • Show other biomarkers of heart failure (e.g. elevated natriuretic peptide or cardiac troponin, two types of protein that the heart releases when it’s damaged) [10, 11]

If you have Stage B heart failure, you may notice that ordinary physical activity is becoming more difficult, or makes you feel tired or winded. [9] At this stage, your healthcare provider may strongly urge you to adopt certain habits that may reduce your chances of CHF's progression. These habits could include [12]:

  • Stopping smoking
  • Reducing your salt intake
  • Reducing your caffeine intake [12]
  • Eating a healthier diet
  • More closely monitoring your health, like noticing swelling or shortness of breath
  • Losing weight

Stage C: Symptomatic Heart Failure

Symptomatic heart failure is the stage that first presents with concrete CHF symptoms. At this level, your heart has sustained structural damage and may cause symptoms such as [13]:

  • Shortness of breath, either when active or resting
  • Cognitive impairment, like confusion or issues with memory
  • Feeling tired or weak
  • Heart palpitations (Read: [Heart Palpitations at Night](https://www.everlywell.com/blog/heart-health/heart-palpitations-at-night/))

Other symptoms of Stage C heart failure tend to vary depending on which part of the heart has been impacted.

For instance, if you have left-sided heart failure, you’ll be more prone to fluid buildup in the lungs, leading to a feeling of short or thin breath. [13] You may also notice [13]:

  • Blue fingers and lips
  • Coughing
  • Sudden, unexplained weight gain
  • Swelling of the abdomen, legs, ankles, and feet
  • Difficulty concentrating

Right-sided heart failure is rarer, but it’s typically associated with fluid buildup throughout the body. [13] You may also experience symptoms like chest discomfort, increased urination, and appetite loss. [13]

Stage D: Advanced Heart Failure

Advanced heart failure (which you may see referred to as AdHF) is the most severe and is often fatal. At this stage (if not Stage C), your healthcare provider may urge you to consider long-term treatments to protect your mortality. These include [3]:

  • A heart transplant
  • A ventricular-assist device (VAD)

Prognosis for Stage D congestive heart failure is worrisome, as most people will require hospitalization and palliative care. [3] At this point, CHF is considered systemic, affecting multiple systems and organs of the body. Around 89% of Stage D CHF patients will lose their lives as a result of pump failure. [3]

Risk Factors for Congestive Heart Failure

Though congestive heart failure is widespread, several diagnosable related health conditions can heighten your risk of developing it. These include:

  • Coronary artery disease (CAD) – CAD is the most prevalent form of heart disease in the US and the most common cause of CHF. [14, 15] When you have CAD, plaque (largely composed of cholesterol) coats the walls of your arteries, which can inhibit and even block blood from circulating. [14]
  • High blood pressure (hypertension) – Hypertension occurs when your heart has to work harder to circulate blood. [16] There are many reasons why you might develop hypertension, from your age, to routinely dealing with high levels of stress.
  • Diabetes – Most people diagnosed with type 2 diabetes are eventually diagnosed with some type of heart disease. [17] In fact, heart disease is the leading cause of death in people with diabetes. Fortunately, appropriately managing diabetes in accordance with your prescribed routine can greatly reduce your risk of CHF. [18]

It’s currently estimated that around half of people diagnosed with heart failure are overweight or obese. [19] If you’re overweight, excess body fat makes it very hard for your heart to do its job. [19] You may also have or be at risk for conditions that contribute to CHF, including hypertension, high cholesterol, diabetes, and more.

Health experts stress that, with obesity-related CHF, losing weight is the keystone of effective treatment. Without it, your heart will continue to work under added stress, making other treatment modalities largely ineffective. [19]

In addition to being overweight, the following lifestyle factors can also put you at higher risk of CHF [1]:

  • Smoking tobacco
  • Using alcohol regularly or in excess
  • Eating a diet that’s high in fat, cholesterol, and/or salt
  • Maintaining an inactive lifestyle

If you’re over the age of 65, or have had a heart attack before, you may also be at risk of CHF. [20]

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Preventing and Managing Congestive Heart Failure

Any CHF diagnosis is a time to open up a conversation with your healthcare provider on short- and long-term solutions.

Can heart failure be reversed? It’s possible it can be reversed or halted if it is diagnosed early. While lifestyle changes are effective—and usually necessary—features of treatment, and interventions like medications (ACE inhibitors, beta-blockers) can also be life-saving. [9] Progressed CHF may require implant devices (e.g. ICDs (implantable cardioverter-defibrillators)) to better control or monitor your heart health. Severe CHF may require transplant surgery.

No matter which type of congestive heart failure you have, making intentional changes to your lifestyle can support you in achieving the best quality of life possible. The most effective means of managing CHF, especially early-stage CHF, include [9]:

  • Eating a heart-healthy diet – Make a habit of eating meals made of whole ingredients. A balanced diet can greatly reduce your risk of amassing bad cholesterol, which can in turn lower your risk of hypertension, diabetes, and other conditions that contribute to CHF.
  • Getting active – Even moving a little bit each day is better for your cardiovascular and whole-body well-being than staying inactive. Regular exercise supports weight loss and weight management and can promote feelings of emotional and physical well-being.
  • Limiting or reducing your alcohol use – It can be hard to cut back or to quit alcohol, but doing so may be the best thing for your long-term health. By the same token, if you smoke, consider exploring your options for quitting with your healthcare provider.
  • Making healthcare a priority – Monitoring your health can be as important as making the changes necessary to improve it. Regular check-ups with your healthcare provider can ensure you catch your blind spots (like high blood pressure or cholesterol levels).

Learning how to improve your resting heart rate may also help your overall heart health.

Care for Your Heart With Everlywell

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References

  1. Heart failure | cdc.gov. Centers for Disease Control and Prevention. Published January 5, 2023. Medical Citation URL. Accessed January 31, 2024.
  2. Professional CCM. Congestive heart failure. Cleveland Clinic. Last reviewed March 10, 2023. Medical Citation URL. Accessed January 31, 2024.
  3. Severino P, Mather P, Pucci M, et al. Advanced Heart Failure and End-Stage Heart Failure: Does a difference exist. Diagnostics. 2019;9(4):170. doi:10.3390/diagnostics9040170. Medical Citation URL. Accessed January 31, 2024.
  4. Universal Definition and Classification of Heart Failure: A Step in the Right Direction from Failure to Function - American College of Cardiology. American College of Cardiology. Published July 12, 2021. Medical Citation URL. Accessed January 31, 2024.
  5. Professional CCM. B-type Natriuretic peptide (BNP) test. Cleveland Clinic. Last reviewed March 3, 2022. Medical Citation URL. Accessed January 31, 2024.
  6. Restivo J. What are the stages of heart failure? Harvard Health. Published December 14, 2023. Medical Citation URL. Accessed January 31, 2024.
  7. Cardiomyopathy - Symptoms and causes - Mayo Clinic. Mayo Clinic. Published April 2, 2022. Medical Citation URL. Accessed January 31, 2024.
  8. Malik A. Congestive heart failure. StatPearls - NCBI Bookshelf. Published November 5, 2023. Medical Citation URL. Accessed January 31, 2024.
  9. Heart failure - Diagnosis and treatment - Mayo Clinic. Published April 20, 2023. Medical Citation URL. Accessed January 31, 2024.
  10. Natriuretic peptide Tests (BNP, NT-ProBNP). Last reviewed December 4, 2023. Medical Citation URL. Accessed January 31, 2024.
  11. Professional CCM. Troponin test. Cleveland Clinic. Last reviewed March 17, 2022. Medical Citation URL. Accessed January 31, 2024.
  12. Congestive heart failure: prevention, treatment and research. Johns Hopkins Medicine. Published April 8, 2022. Medical Citation URL. Accessed January 31, 2024.
  13. Heart failure symptoms. Johns Hopkins Medicine. Published July 11, 2022. Medical Citation URL. Accessed January 31, 2024.
  14. Coronary Artery Disease | Cdc.gov. Centers for Disease Control and Prevention. Published July 19, 2021. Medical Citation URL. Accessed January 31, 2024.
  15. Congestive heart failure (CHF). Yale Medicine. Published January 25, 2023. Medical Citation URL. Accessed January 31, 2024.
  16. Heart failure - Symptoms and causes - Mayo Clinic. Mayo Clinic. Published April 20, 2023. Medical Citation URL. Accessed January 31, 2024.
  17. Diabetes and heart disease. Johns Hopkins Medicine. Published November 6, 2023. Medical Citation URL. Accessed January 31, 2024.
  18. Shen J, Greenberg B. Diabetes Management in Patients with Heart Failure. Diabetes & Metabolism Journal. 2021;45(2):158-172. doi:10.4093/dmj.2020.0296. Medical Citation URL. Accessed January 31, 2024.
  19. Shen Q, Hiebert JM, Rahman F, Krueger KJ, Gupta B, Pierce JD. Understanding Obesity-Related High Output heart Failure and its implications. International Journal of Heart Failure. 2021;3(3):160. doi:10.36628/ijhf.2020.0047. Medical Citation URL. Accessed January 31, 2024.
  20. Heart health and aging. National Institute on Aging. Last reviewed June 1, 2018. Medical Citation URL. Accessed January 31, 2024.
Jordan Stachel, M.S., RDN, CPT is most fulfilled when guiding others towards making stepwise, sustainable changes that add up to big results over time. Jordan works with a wide variety of individuals, ranging in age from children to the elderly, with an assortment of concerns and clinical conditions, and has written for publications such as Innerbody. She helps individuals optimize overall health and/or manage disease states using personalized medical nutrition therapy techniques.
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