Understanding the four stages of heart failure

Written by: Dr Kare Tang
Published: | Updated: 27/07/2021
Edited by: Cameron Gibson-Watt

Heart failure occurs when the heart is unable to pump blood around the body properly because it has become too weak or stiff. If you have recently been diagnosed with heart failure, your treatment plan will depend on the stage at which your heart failure has been determined.

Dr Kare Tang, a consultant cardiologist based in London, Colchester and Basildon, walks us through these four stages and offers us an insight into what a treatment plan might look like for each stage.



What are the main causes of heart failure?

Heart failure can have many causes. The most common causes are:


  • Coronary heart disease – this is where the arteries that supply blood to the heart become clogged up with fatty substances called atherosclerosis which may cause symptoms of chest discomfort called angina or heart damage from a heart attack.
  • Hypertension – high blood pressure can put extra strain on the heart, which over time can lead to heart failure.
  • Cardiomyopathy – conditions affecting the heart muscle and can be hereditary or acquired condition that causes the changes in the heart muscle tissue leading to failure of function.
  • Arrhythmias – heart rhythm problems such as atrial fibrillation which impairs the contraction strength of the heart by the persistent fast heart rate is one of the many rhythm disturbances causing the heart to pump less efficiently.
  • Heart valve disease – valve defects and damage will increase volume and strain on the heart and weaken it.
  • Congenital heart disease – birth defects that affect the normal workings of the heart.
  • Metabolic – hyperthyroid with overactive thyroid and diabetes are endocrine causes of heart failure.
  • Toxicity – alcohol and certain chemotherapy drugs can be toxic to the muscle cells and damage their function.


How is heart failure treated/managed?

Treatment of heart failure depends on the underlying cause and this will direct the main treatment to prevent further deterioration. Heart failure can be cured if it has a treatable cause.


If the causes are due to coronary heart disease then the patient may require coronary stents or bypass surgery. If there is a heart valve cause, then the defective valve will need surgery to repair or replace the valve.


All heart failure patients will need: 

  • Lifestyle changes – including eating a healthy diet, exercising regularly and stopping smoking and watching fluid intake and reduce alcohol consumption.
  • Medicine – a range of medicines can help; many people need to take three to four different types which have evidence to show they strengthen the heart and improve prognosis. This includes beta-blockers, ACE inhibitors, ARNI and SGLT2 inhibitors. Other medicines, such as diuretics, may be used to help with the symptoms.


In cases where patients are seen to be experiencing continued deteriorating heart function despite the best and optimal medication, the following may be considered:

  • Cardiac resynchronising therapy – In very severe heart failure conditions, a specialised type of pacemaker has shown to benefit and improve symptoms as well as prolonging life by resynchronising the contractility of the two main pumping chambers of the heart. 
  • Cardiac transplant – If there is no scope for recovery and the condition deteriorates then in suitable patients, a heart transplant may be considered.


Treatment for heart failure usually aims to control the symptoms for as long as possible and slow down the progression of the condition. Treatment will usually be needed for life.

What are the 4 stages of heart failure?

There are four stages of heart failure - stage A, B, C and D - which range from high risk of developing heart failure to advanced heart failure.


The four stages of heart failure are different to the four classes of heart failure symptoms also described in New York Heart Association (NYHA), which illustrates the severity of symptoms, ranging from class one (no symptoms) to the most severe, which is class four (with symptoms at rest).


Stage A

Stage A is considered pre-heart failure. It means you are at high risk of developing heart failure because you have a family history of heart failure or you have one or more of these medical conditions:



Stage B

Stage B is considered to be asymptomatic or silent heart failure. It means you have been diagnosed with systolic left ventricular dysfunction but have never had symptoms of heart failure. Most people with Stage B heart failure have an echocardiogram (echo) that shows an ejection fraction (EF) of 40 per cent or less. This category includes people who have heart failure and reduced EF (HF rEF) due to any cause.


Stage C

Patients with stage C heart failure have been diagnosed with heart failure and have (currently) or had (previously) signs and symptoms.


There are many possible symptoms of heart failure. The most common are:


Stage D

Patients with Stage D have advanced symptoms that do not get better with treatment. This is the final stage of heart failure. They are likely to have NYHA class three to four symptoms, which means they show symptoms on mild or minimal exertion or at rest.

What might a treatment plan look like for each stage?


Stage A treatment

The usual treatment plan for patients with Stage A heart failure is primary prevention which includes:


  • regular exercise, being active, walking every day
  • quitting smoking
  • treatment for high blood pressure (medication, low-sodium diet, active lifestyle)
  • treatment for high cholesterol
  • not drinking alcohol or using recreational drugs
  • medications for an underlying cause such as diabetes


Stage B treatment

The usual treatment plan for patients with Stage B heart failure includes:


  • treatments listed in Stage A
  • angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) 
  • beta-blocker if you have had a heart attack and your EF is 40% or lower
  • aldosterone antagonist if you have had a heart attack or if you have diabetes and an EF of 35% or less (to reduce the risk of your heart muscle getting bigger and pumping poorly).
  • SGLT2 inhibitor medication
  • possible surgery or intervention as a treatment for coronary artery blockage, heart attack, or valve disease


Stage C treatment

The usual treatment plan for patients with Stage C HF-rEF includes:


  • treatments listed in Stages A and B
  • (ACE-I, ARB or angiotensin receptor/neprilysin inhibitor combination) 
  • Hydralazine/nitrate combination if other treatments don't stop your symptoms. Patients who are African-American should take this medication (even if they are taking other vasodilator medications) if they have moderate-to-severe symptoms
  • Medications that slow the heart rate if your heart rate is faster than 70 beats per minute and you still have symptoms despite beta-blocker
  • diuretic ("water pill") may be prescribed if symptoms continue
  • restrict sodium (salt) in your diet
  • keep track of your weight every day to assess for fluid retention
  • possible fluid restriction
  • possible cardiac resynchronisation therapy (biventricular pacemaker)
  • possible implantable cardiac defibrillator (lCD) therapy


Stage D treatment

The usual treatment plan for patients with Stage D heart failure includes:


  • Treatments listed in Stages A, B and C
  • Evaluation for more advanced treatment options, including heart transplant, ventricular assist devices, heart surgery, continuous infusion of intravenous inotropic drugs, palliative or hospice care or research therapies


Worried about any of the symptoms mentioned in this article? You can make an appointment with one of our top consultant cardiologists, Dr Kare Tang, by going to his Top Doctors profile and checking his availability.

By Dr Kare Tang

Dr Kare Tang is a renowned consultant cardiologist with leading expertise in general cardiology and interventional cardiology. He trained extensively in various institutions in the UK and has spent more than 20 years providing healthcare within the NHS and to private patients. Among his many areas of expertise are heart failure, valvular heart diseases, hypertension (high blood pressure), cardiac screening and cardiac arrhythmia and coronary artery disease.

His incredibly high level of expertise makes him the chosen surgeon for many when it comes to very high-risk procedures. Dr Tang regularly performs complex and routine procedures such as coronary and heart catheterization, angioplasty (stents) and pacemaker implantation, among many others.

His extensive training took place in highly regarded institutions. After receiving his Bachelor's of Medicine in 1991, Dr Tang went on to train at Papworth and Addenbrookes Hospital (Cambridge) and Hammersmith Hospital (London), both of which are renowned cardiac centres. After this, he pursued additional training to further hone his skills in Hong Kong at the Prince of Wales Chinese University. After this training, he returned to the UK and has worked for the NHS and at various private clinics across London, Colchester and Basildon. 

Furthermore, Dr Tang is passionate about improving the field of cardiology via research. He is the principal investigator for seven major trials in the treatment of coronary artery disease and he has over 40 peer-reviewed research publications in prestigious journals.

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