Heart Failure

STAGES OF HEART FAILURE^1,2

CLASS I
No symptoms or limitations to physical activity.

CLASS II
Slight limitations of physical activity. Comfortable at rest; ordinary physical activity results in feeling tired and shortness of breath.

CLASS III
Significant limitations of physical activity. Less than ordinary activity causes results in feeling tired and shortness of breath.

CLASS IV
Unable to carry on any physical activity without discomfort. Tired and shortness of breath even at rest.

*INTERMACS Registry = Interagency Registry for Mechanically Assisted Circulatory Support

INTERMACS PROFILES

NYHA classification does not offer adequate description to allow optimal selection of patients for current options of medical and device therapies, HTx and MCS
NYHA III and IV Patients who may be considered for MCS can now be classified using 7 INTERMACS profiles.

MECHANICAL CIRCULATORY SUPPORT (MCS)

Indications for short- and long-term MCS should be based on the INTERMACS profiles⁴

^aThis algorithm can be applied to all patients with advanced HF defined according to the HFA-ESC criteria,⁵ with exception of hypertrophic cardiomyopathy (HCM), cardiac arrest (CA), arrhythmic storm, adult congenital heart disease, refractory angina.

^bRecurrent hospitalization, progressive end-organ failure, refractory congestion, inability to perform cardiopulmonary exercise test or peak oxygen consumption <12 mL/min/kg or <50% of expected value.⁶

Colour code for classes of recommendation: Green for Class of recommendation I and Yellow for Class of recommendation IIa.

INTERAGENCY REGISTRY FOR MECHANICALLY ASSISTED CIRCULATORY SUPPORT PROFILE DESCRIPTIONS OF PATIENTS WITH ADVANCED HEART FAILURE⁴

Profile	Time frame for intervention
Proﬁle 1. Critical cardiogenic shock Patient with life-threatening hypotension despite rapidly escalating inotropic support, critical organ hypoperfusion, often conﬁrmed by worsening acidosis and/or lactate levels.“Crash and burn.”	Deﬁnitive intervention needed within hours.
Proﬁle 2. Progressive decline Patient with declining function despite i.v. inotropic support, may be manifest by worsening renal function, nutritional depletion, inability to restore volume balance. “Sliding on inotropes.” Also describes declining status in patients unable to tolerate inotropic therapy.	Definitive intervention needed within few days.
Proﬁle 3. Stable on inotrope or inotrope-dependent Patient with stable blood pressure, organfunction, nutrition, and symptoms on continuous i.v. inotropic support (or a temporary circulatory support device or both) but demonstrating repeated failure to wean from support due to recurrent symptomatic hypotension or renal dysfunction. “Dependent stability.”	Definitive intervention elective over a period of weeks to few months.
Proﬁle 4. Frequent Flyer Patient can be stabilized close to normal volume status but experiences daily symptoms of congestion at rest or during activities of daily living. Doses of diuretics generally ﬂuctuate at very high levels. More intensive management and surveillance strategies should be considered, which may in some cases reveal poor compliance that would compro-mise outcomes with any therapy. Some patients may shuttle between 4 and 5.	Definitive intervention elective over a period of weeks to few months.
Proﬁle 5. Housebound Comfortable at rest and with activities of daily living but unable to engage in any other activity, living predominantly within the house. Patients are comfortable at rest without congestive symptoms, but may have underlying refractory elevated volume status, often with renal dysfunction. If underlying nutritional status and organ function are marginal, patients may be more at risk than INTERMACS 4, and require deﬁnitive intervention.	Variable urgency, depends upon maintenance of nutrition, organ function, and activity.
Profile 6. Exertion limited Patient without evidence of fluid overload, comfortable at rest and with activities of daily living and minor activities outside the home but fatigues after the first few minutes of any meaningful activity. Attribution to cardiac limitation requires careful measurement of peak oxygen consumption, in some cases with haemodynamic monitoring, to confirm severity of cardiac impairment. “Walking wounded.”	Variable, depends upon maintenance of nutrition, organ function, and activity level.
Profile 7. Advanced NYHA class III symptoms Patient without current or recent episodes of unstable fluid balance, living comfortably with meaningful activity limited to mild physical exertion.	Heart transplantation or MCS may not be currently indicated.
Modifiers for profiles	Possible profiles that can be modified
Temporary MCS can modify profile only in hospitalized patients. They include IABP, ECMO, TandemHeart, LVAD, Impella.	1, 2, 3
Arrhythmia can modify any profile. They include recurrent ventricular tachyarrhythmias that have recently contributed substantially to clinical compromise, frequent ICD shocks or requirement for external defibrillation, usually more than twice weekly.	1-7
Frequent episodes of HF decompensation characterize patients requiring frequent emergency visits or hospitalizations for diuretics, ultrafiltration, or temporary i.v. vasoactive therapy. Frequent episodes may be considered as at least two emergency visits/admissions in the past 3 months or three in the past 6 months.	3 if at home, 4, 5, 6. Rarely for profile 7.

BTB=bridge to bridge; BTC=bridge to candidacy; BTD=bridge to decision; BTR=bridge to recovery; BTT=bridge to transplantation; CA=cardiac amyloidosis; DT=destination therapy; ECMO=extracorporeal membrane oxygenation; ESC=European Society of Cardiology; HCM=hypertrophic cardiomyopathy; HF=heart failure; HFA=Heart Failure Association; HT or HTx=heart transplantation; IABP=intra-aortic balloon pump; ICD=implantable cardioverter-defibrillator; INTERMACS=Interagency Registry for Mechanically Assisted Circulatory Support; i.v.=intravenous; LVAD=left ventricular assist device; LVAD-BTC=left ventricular assist device - bridge to candidacy; LVAD-DT=left ventricular assist device - destination therapy; MCS=mechanical circulatory support; NYHA=New York Heart Association.

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References

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www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/classes-of-heart-failure. Accessed July 2023.
Teuteberg JJ, Cleveland JC, Cowger J, et al. The Society of Thoracic Surgeons Intermacs 2019 Annual Report: The changing landscape of devices and indications. Ann Thorac Surg. 2020;109(3):649–60. doi.org/10.1016/j.athoracsur.2019.12.005.
McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599–3726. doi.org/10.1093/eurheartj/ehab368.
Eisman AS, Shah RV, Dhakal BP, et al. Pulmonary capillary wedge pressure patterns during exercise predict exercise capacity and incident heart failure. Circ Heart Fail. 2018;11(5):e004750. doi.org/10.1161/CIRCHEARTFAILURE.117.004750.
Mehra MR, Canter CE, Hannan MM, et al. The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: a 10-year update. J Heart Lung Transplant. 2016;35(1):1–23. doi.org/10.1016/j.healun.2015.10.023.
Stevenson LW, Pagani FD, Young JB, et al. INTERMACS profiles of advanced heart failure: the current picture. J Heart Lung Transplant. 2009;28(6):535–541. doi.org/10.1016/j.healun.2009.02.015.