In short: Heart failure is usually graded into four classes (NYHA I–IV) by how much it limits everyday activity. Class I: no symptoms with normal activity. Class II: symptoms with ordinary activity. Class III: symptoms with even light activity. Class IV: symptoms at rest. A separate system (ACC/AHA stages A–D) tracks how the disease progresses. Treatment can improve symptoms and move people to a lower class.
Medically reviewed by Dr Georgios Karagiannis MD PhD FRCP FHFA, Consultant Cardiologist and honorary consultant in advanced heart failure, Harefield Hospital · Last reviewed:
Heart failure is a condition that affects around 900,000 people in the UK. It is a serious condition that occurs when your heart cannot pump blood properly around your body.
However, despite its severity, it can be managed and treated so that people can live perfectly normal lives – especially if it’s detected early enough.
In this article, we’ll explain the four stages of heart failure, how they’re treated and what stage 4 heart failure looks like. Discover all you need to know about stage 4 heart failure with Expert Cardiologist.
What is heart failure?
Heart failure does not mean your heart has stopped – it simply means that your heart cannot do its job effectively (pump blood around your body).
During heart failure, your heart can’t pump blood with as much strength as it should. When this occurs, your body cannot get enough oxygen.
Blood may also begin to collect in your veins, leading to swelling in areas such as your feet and legs. You may also experience shortness of breath on exertion, which gradually worsens and occurs even when at rest.
Stiff or weak ventricles of your heart can also cause heart failure. Generally, this occurs because of factors like heart disease, diabetes, smoking, obesity and a prolonged lack of physical activity.
Heart failure is a long-term condition that can get progressively worse, especially if it remains undiagnosed and untreated.
Breathlessness on exertion
Getting out of breath when exercising is normal, but as breathlessness on exertion is a common symptom of heart failure, knowing the difference is important.
If you get out of breath when exercising or completing a lot of physical activity, then feeling breathless can be normal.
However, if you experience breathlessness when completing everyday activities that aren’t causing you to exert yourself, it could indicate a potential cardiovascular problem.
The stages of heart failure: from stage 1 to stage 4 heart failure
There are four distinct stages of heart failure, ranging from stage 1 (relatively mild) to stage 4 (extremely serious).
Depending on the stage of heart failure you’re at, you may not notice your symptoms at all or simply experience breathlessness on exertion. At a later stage, you may feel your symptoms even when at rest.
The four stages of heart failure will help your cardiologist determine the severity of your condition and what treatment you need.
Stage 1 heart failure
In stage 1 heart failure, you might experience no symptoms during your daily activities. Treatment generally focuses on lifestyle changes like exercising more, improving your diet and stopping smoking.
Your cardiologist will also recommend managing other underlying health conditions that can cause heart failure (like diabetes).
Stage 2 heart failure
At this stage, you’ll probably only notice your symptoms during physical activity.
Treatment for stage 2 heart failure can include lifestyle changes, and you may be given specific medication to support your heart. The prescribed medication depends on your specific heart failure and whether you have had a heart attack or if you already have diabetes.
Medications used to treat stage 2 heart failure include:
- Beta-blockers
- SGLT2 inhibitors
- MRAs
- ACE-I
Surgery may be considered if there’s a blockage or valve issue.
Stage 3 heart failure
If you have stage 3 heart failure, even the most basic forms of physical exercise can cause symptoms – even if you do not experience them at rest. Some of the most common symptoms can include shortness of breath, exhaustion and swelling in your feet, ankles, legs and lower abdomen.
At this point, your cardiologist will consider a wider range of treatment options. They’ll recommend the same lifestyle changes and medications mentioned in stages 1 and 2 and may prescribe additional or stronger medications.
Medications for stage 3 heart failure can include:
- ACE inhibitors
- Beta-blockers
- Diuretics
- SGLT2 inhibitors
- Mineralocorticoid blockers
Your cardiologist may also recommend cardiac resynchronisation therapy to address a heartbeat issue or a cardioverter-defibrillator implant to help your heart.
Stage 4 heart failure
Stage 4 heart failure is the most severe. You’ll show symptoms regardless of whether you’re exercising or resting. You may feel shortness of breath, nausea, light-headedness, chest pain, and swelling, even when you are completely at rest.
Generally, stage 4 heart failure will be treated in a hospital where the goal is to slow its progression and enhance your quality of life. Sometimes, you may need surgery to address blocked arteries or faulty valves to improve blood flow and reduce your heart failure symptoms.
Surgeries that may be performed to improve stage 4 heart failure symptoms include:
- Coronary artery bypass graft
- Heart valve repair or replacement
- Heart transplant
- Implantable devices like a pacemaker
Can stage 4 heart failure be reversed?
For most people, heart failure cannot be reversed. The condition requires management with proper treatment. However, the treatment depends largely on the stage of heart failure.
Although there’s no cure for heart failure, treatments such as medication, surgery or surgical implants can help control the symptoms.
You can also make many changes to your lifestyle that will slow down heart failure, including avoiding alcohol, smoking and drugs while exercising and eating a well-balanced diet.
Frequently asked questions
What are the signs of end-stage (stage 4) heart failure?
Breathlessness at rest or when lying flat, severe tiredness, swelling of the legs and abdomen despite water tablets, poor appetite, weight loss, low blood pressure and repeated hospital admissions. At this stage, options may include advanced therapies such as heart pumps or transplantation, or palliative care focused on comfort.
What is the difference between NYHA classes and ACC/AHA stages?
NYHA classes (I–IV) describe current symptoms and can go up or down with treatment. ACC/AHA stages (A–D) describe disease progression, from being at risk (A) to advanced heart failure (D), and only move forward. Cardiologists often use both.
Can you go back a stage of heart failure?
You can move to a lower NYHA class. With modern medicines (ACE inhibitors or ARNI, beta-blockers, MRAs and SGLT2 inhibitors), devices and lifestyle changes, many people feel much better and some recover heart pump function. The underlying ACC/AHA stage does not go backwards.
How long can you live with heart failure?
Outlook varies widely with the cause, the class, age and other conditions. It has improved a lot with current treatments, and many people live for many years. Your cardiologist can give a more personal outlook after tests such as an echocardiogram and blood tests.
What are the early signs of heart failure?
Breathlessness with activities that used to be easy, swollen ankles, tiredness, needing extra pillows at night, and sudden weight gain from fluid. Early diagnosis with an NT-proBNP blood test and echocardiogram means treatment can start sooner.
When to seek help for heart failure
Although heart failure can seem scary, you must seek help for any potential problems or symptoms you’re experiencing. It’s also a good idea to have a healthy heart check if your family has a history of heart failure or heart disease, or if it has been a while since your last check-up.
At Expert Cardiologist, we can help you at every step. We perform numerous heart tests to determine what’s going on, and we’ll walk you through any treatment options you may need.
As a team, we understand how challenging it can be to deal with this condition, which is why we are proud to offer high-quality patient care and expert advice.
Book your cardiovascular consultation with our team today.
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