What Are the 4 Stages of Congestive Heart Failure?

Although it can be scary to be told that you (or a loved one) have congestive heart failure, the name implies a more dire condition than it necessarily is. It does not mean that the heart fails or stops functioning altogether—but it does start functioning less well. “It’s a disease where the heart can’t pump the blood well enough to support the needs of the body,” says Anum Minhas, M.D., a cardiologist and an assistant professor of medicine at Johns Hopkins Medicine in Bethesda, MD. “That’s why you may feel fatigued and short of breath.”

The disease is also typically progressive, meaning these symptoms and others can become worse over time—which is why doctors classify the progression in four stages, based on the severity of symptoms. And while this is a serious condition, in most cases there are measures you can take to help relieve symptoms and slow or stop the progression.

Note that the medical community recently dropped the word “congestive” when identifying heart failure: The term refers to the buildup of fluid in the ankles and feet, arms, lungs, and/or other organs that might occur as blood backs up and fluid seeps through capillary walls, per Yale Medicine. “The word fell out of favor because it was inaccurate; not every patient is congested all the time, so patients can find that word confusing,” says Dr. Minhas. “It’s clearer to just say heart failure because it’s the larger umbrella term that encompasses every stage.”

Here, we’ll explore how the heart functions, and what each stage of the condition means.

So how does a healthy heart function? Remember, your heart is a muscle whose main purpose is to pump blood throughout the body. “To determine how much blood the heart pumps out with each heartbeat, physicians use a measurement called an ejection fraction,” says Marat Fudim, M.D., an assistant professor of medicine, cardiology, at Duke Cardiology Clinic in Durham, NC.

The ejection fraction is measured as a percentage of the total amount of blood in your heart that is pumped out with each beat. A normal ejection fraction is 50% or more, meaning at least half of the volume of blood is pushed out of the heart as it beats. Below that number, your heart isn’t pumping enough blood, and may be failing.

There are two different types of heart muscle impairment which can cause your ejection fraction to be compromised, which your doctor will specify. “If your squeeze is reduced because you have a weak heart, we call that reduced ejection fraction because the ejection is reduced; it’s less than 50%,” explains Dr. Fudim.

“But sometimes you can have a normal ejection fraction measurement and still have heart failure. This is called preserved ejection fraction, when your heart muscle becomes thick and stiff, usually a result of high blood pressure,” says Dr. Fudim. The heart needs to relax after it contracts so it can fill with enough blood. “When the muscle is too stiff, even though it’s pumping enough blood, the heart can only hold a smaller-than-needed amount,” he adds.

Because heart failure is a progressive condition, the American College of Cardiology together with the American Heart Association developed these four stages of diagnosis, which range in severity of heart damage.

Stage A

If you have obesity, hypertension, coronary vascular disease, diabetes, or some combination of these conditions, or if you have a strong family history of heart failure, you are already in stage A. “At this initial stage, a person is only at risk for heart failure, but there’s no actual symptoms or structural disease. That means that visibly the heart looks and pumps OK,” says Dr. Fudim. “You can exercise and do your daily activities with no trouble.”

But while you have a higher risk of developing progressive heart failure in stage A, here’s the headline: This is the stage where you can actually affect your diagnosis. “What most people don’t know is that a healthy lifestyle is the best way to prevent heart failure or at least delay its onset. In fact, prevention is the best therapy,” says Dr. Fudim.

There is a lot of science that bears this out. Medical records taken from almost 21,000 men from the Physicians Health Study over a 20-year span revealed that 1,200 of them developed heart failure. Those who didn’t smoke, exercised regularly, weren’t overweight, drank alcohol in moderation, and ate the highest amounts of fruits and vegetables had “a substantially lower risk of lifetime risk of heart failure” with the highest risk in men who didn’t do any of these actions. Other large studies that also included women reached the same conclusions.

Stage B

In stage B, often the left ventricle in your heart isn’t working well, but you still don’t show symptoms. “In this stage, we do see structural heart disease and abnormal function, but the person isn’t experiencing any symptoms of heart failure,” says Dr. Minhas. Typically, stage B is diagnosed with an echocardiogram that shows an ejection fraction of 40% or less. The test might be given if you are in the stage A high-risk group to determine whether actual changes have occurred to the heart.

In addition to stressing healthy lifestyle changes, your doctor will likely introduce some combination of the following medications to help improve your heart function, with the aim of preventing or delaying the transition to worsening stages of heart failure (your ultimate goal at this stage).

Stage C

In this stage, you have both a heart failure diagnosis and you’re experiencing symptoms that include shortness of breath from minimal movement like walking down the hall; dizziness even at rest; feet, leg, and belly swelling; weight gain; and/or chest pains.

“In Stage C, we continue to treat with heart failure medications, and to stress the benefits of lifestyle interventions,” says Dr. Fudim. For example, he notes, “we encourage losing weight—it goes a long way in helping to treat comorbidities such as high blood pressure and diabetes.”

Your prognosis at this stage will depend on your ejection fraction percentage, your symptoms, how well you follow your treatment plan, and how well your body responds to it. Studies examining heart failure outlook vary, “but in general, about 50% of patients who get hospitalized for heart failure survive for five years thereafter,” says Dr. Fudim.

Stage D

Unfortunately, this stage means your disease has advanced and medical treatment alone is no longer working. (Of the more than 6 million American adults living with heart failure, about 10% reach this stage.) “Depending on your particular condition, your cardiologist may talk to you about surgical procedures such as getting a heart transplant, or a left ventricular assist device (VAD), among other options,” says Dr. Fudim. “At this point, patients require this kind of intervention to stay alive and hospitalization is common.” Note that many of these procedures come with significant risks, he says, and patients may also want to consider hospice or palliative care. According to a review in the journal Current Opinion in Cardiology, Stage D patients have an average survival of between six months and one year.

You don’t have to wait until you are in Stage A of heart failure to take action against this condition. Making smart lifestyle choices—including eating right and exercising, as well as stopping smoking if you’ve developed this habit—can go a long way toward keeping your heart (and the rest of you) at full function for many years to come.

When it comes to eating healthier, consider following the National Heart, Lung, and Blood Institute’s Dietary Approaches to Stop Hypertension (DASH) diet, which has been shown to lower blood pressure and heart failure risk. One small study found those with heart failure who embraced the DASH diet actually improved their heart function. “So even if you can’t prevent heart failure altogether, you can definitely take action to delay its worsening,” says Dr. Fudim.

While heart failure cannot be cured once you’ve reached the later stages, you can halt or slow the disease process down, “if you initiate a healthy lifestyle by stopping smoking, losing weight, starting an exercise routine, and avoiding excessive alcohol, which can contribute to fluid retention,” says Dr. Fudim. “Another positive is that in conjunction with adopting healthy habits, medications have advanced that can very well stabilize that downward trajectory for years, maybe decades.”

If you fall into a high-risk group, or if you have symptoms of heart failure like shortness of breath, talk to your health care provider right away. The sooner you can get diagnosed and onto the right treatment plan, the better your outlook will be.

This article was originally published November 22, 2023 and most recently updated November 29, 2023.

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