Congestive Heart Failure Stages: What Are They and How Are They Treated?

Congestive heart failure (CHF) happens when the heart becomes weak and can’t pump blood effectively to meet the demands of your body. It’s a chronic condition that worsens over time, and there are four stages of the disease. These stages range from “high risk of developing heart failure” to “advanced heart failure.”

As your CHF gets worse, your heart muscle pumps less blood to your organs and you progress through the stages. You cannot go backward even with treatment. Therefore, the goal of treatment is to stop you from progressing or to slow down the progression.

Your doctor can tell you how severe your heart failure is using a number of tests.

Stage A

Stage A is considered the first stage of heart failure. Technically, people in this stage don't have any evidence of heart failure but are considered to be at higher risk for developing heart failure due to family history, personal health history, and lifestyle choices.

While you don’t have symptoms of heart failure, you could have other conditions that lead to heart failure, including:

• Hypertension (high blood pressure)
• Diabetes
• Coronary artery disease
• Metabolic syndrome, which are conditions that increase the risk of heart disease, stroke, and diabetes

Other risk factors that will place you in stage A include:

• A history of alcohol and drug abuse
• A history of rheumatic fever, which results from inadequately treated strep throat or scarlet fever
• A family history of cardiomyopathy, a disease of the heart muscle that makes it harder for the heart to deliver blood to the rest of the body
• Having taken certain medications that can weaken the heart muscle, like chemotherapy drugs

Stage A Treatment Options 

Treatment options in stage A mainly focus on promoting your overall health and disease prevention. If you meet the stage A criteria, your doctor will recommend lifestyle changes to slow or stop disease progression.

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The usual treatment plan for stage A can include:

• Engaging in regular, daily exercise
• Quitting smoking
• Treating high blood pressure with medications, a low-sodium diet, and an active lifestyle
• Lowering your cholesterol levels
• Not drinking alcohol or using recreational drugs

Stage B

Stage B is the second stage of heart failure, but it’s considered "pre-heart failure". You don’t have symptoms of heart failure, but there may be evidence of structural heart disease.

People at stage B typically have an ejection fraction (EF) of 40% or less. This stage includes people who have heart failure and a reduced EF due to any cause.

People at this stage may have some slight symptoms like:

• Slight physical limitations
• Fatigue
• Shortness of breath with physical activity

Stage B Treatment Options

While stage A CHF is managed with lifestyle changes, the treatment plan for stage B typically includes taking medications regularly. People at this stage should still make the same lifestyle changes as those appropriate for stage A. However, your doctor may also prescribe additional treatments such as:

• Angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, if you aren’t taking any as part of your stage A treatment plan
• Beta blockers if you’ve had a heart attack and your EF is 40% or lower, if you aren’t taking any as part of your stage A treatment plan
• Possible surgery or intervention as a treatment for coronary artery blockage, heart attack, valve disease, or congenital heart disease

Stage C

Stage C is the first significant stage of heart failure in terms of how you feel. At this stage, you have been officially diagnosed with heart failure and have or had symptoms. Symptoms in this stage include:

• Noticeable limitations of physical activity
• Shortness of breath with activity
• A low tolerance for activity, easily tired
• Heart palpitations or chest pain
• Most comfortable when you are resting

Stage C Treatment Options 

Treatment at this stage focuses on managing your symptoms, optimizing your heart function, and preventing worsening of your condition.

Medications to treat stage C heart failure include:

• Diuretics to reduce fluid retention
• Beta blockers to help make your heart work less hard
• SGLT2 inhibitors to reduce the risk of cardiovascular death and hospitalization for heart failure
• Angiotensin-converting enzyme inhibitors
• Angiotensin II receptor blockers
• Entresto (sacubitril and valsartan), which reduces the risk of death and hospitalization among patients with chronic heart failure
• Aldosterone antagonists
• Ivabradine
• Isosorbide dinitrate and hydralazine
• Digoxin to help the heart beat stronger and more regularly
• Possible cardiac resynchronization therapy (biventricular pacemaker)
• Possible implantable cardiac defibrillator (ICD) therapy

In addition to the lifestyle changes for stages A and B, you may need to make the following changes:

• Reduce your sodium intake
• Restrict fluid intake
• Keep track of your weight daily (tell your healthcare provider if you gain or lose two pounds in a day or five pounds in a week)

Remember that even if the treatment causes your symptoms to get better or stop, you still need to continue treatment to slow the progression of your condition to stage D.

Stage D

Stage D is advanced or severe heart failure. At this point, medications and other treatments don’t offer much relief from symptoms. Your symptoms are similar to those in stage C, but more severe. It may be difficult to do much physically without becoming severely tired or out of breath.

You may also experience multiple organ failure as your blood pressure drops. When the heart can’t pump strongly enough, it can’t pump blood out to vital organs.

Other problems you may experience elsewhere in the body include:

• Abdominal pain or discomfort
• Kidney disease
• Liver disease
• Difficulty walking

Stage D Treatment Options

While you may continue with treatment from the previous stages of heart failure, severe heart failure treatment may also include:

• Heart transplantation
• Mechanical circulatory support, which includes devices that help the heart to pump blood to the body and vital organs
• Heart surgery
• Intravenous medications to offer continuous support to your heart muscles
• Palliative or hospice care

Prevention

Heart failure is a chronic, progressive disease. Once you have reached a certain stage, you may be able to slow its progression, but you can’t undo damage that has already been done to the heart. For this reason, prevention is a key strategy, especially for people with risk factors of CHF.

Heart failure prevention focuses on managing your:

• Weight
• Cholesterol
• Blood pressure
• Diabetes

You can also decrease your risk of developing heart failure by:

• Avoiding alcohol and drugs
• Exercising regularly
• Eating lots of fruits, vegetables, and fish

Summary

Congestive heart failure is a chronic condition that can progress. The stages range from pre-heart failure to advanced heart failure. Once you move on to the next stage, you can’t go back even with treatment.

However, if caught early, it’s possible to delay or stop disease progression with lifestyle changes and medications. If you have risk factors of heart failure, discuss with your doctor how best to prevent developing the condition.

Frequently Asked Questions

What should I expect in the end stage of congestive heart failure?

In the end stages of heart failure, most physical activities will become difficult. You will likely require frequent or prolonged hospitalization or need home health or skilled nursing care. You may also need to wear oxygen or receive intravenous medications.

What is the life expectancy for someone with congestive heart failure?

Your quality of life and outlook depend on your treatment plan, how well you respond to treatment, and how well you follow your treatment plan.

What happens to your blood pressure in advanced stages of congestive heart failure?

While high blood pressure generally leads up to heart failure, blood pressure tends to drop in end-stage heart failure. The heart can’t pump blood as forcefully, and lower blood pressures in late-stage heart failure usually signal a higher risk of death.

Is heart failure genetic?

Heart failure itself isn’t necessarily genetic, but some conditions—like hypertension, inherited cardiomyopathies, and others—can lead to heart failure. Make sure to discuss your family’s medical history with your doctor so they can help you identify your genetic health risks.