The Omnicare HealthLine

Focus on Heart Failure, Part 1: Classifications and Causes - by Allen Lefkovitz

The American Heart Association defines heart failure (HF) as “a chronic, progressive condition in which the heart muscle is unable to pump enough blood through to meet the body’s needs for blood and oxygen.” In trying to compensate, the heart may enlarge and may pump faster. HF is a leading cause of cardiovascular death and accounts for 1 in 9 deaths in the United States. HF is considered a leading cause of hospitalizations and hospital readmissions among older adults. Since the initiation of the Hospital Readmission Reduction Program in October 2012, HF has been targeted as one of the leading causes of excess 30 day-readmissions. Estimates from a few years ago stated the prevalence of HF among skilled nursing facility (SNF) residents to be between 20% and 37.4%. Additionally, 4.3% of SNF residents had HF as a primary diagnosis during the admission process.

Two systems are commonly utilized for classifying the severity of HF symptoms:

• The American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) Stages
• The New York Heart Association (NYHA) Functional Classifications

A comparison of these two systems is located in the table below.


A: At high risk for HF, but without structural
heart disease or symptoms of HF

B: Structural heart disease but without
signs or symptoms of HF

C: Structural heart disease with prior
or current symptoms of HF

D: Refractory HF requiring specialized interventions

NYHA Functional Classifications


I. No limitation of physical activity. Ordinary physical
activity does not cause symptoms of HF.

II. Slight limitation of physical activity. Comfortable at rest,
but ordinary physical activity results in symptoms of HF.

III. Marked limitation of physical activity. Comfortable at rest,
but less than ordinary activity causes symptoms of HF.

IV. Unable to carry on any physical activity without
symptoms of HF, or symptoms of HF at rest.

In addition to these classification systems, HF is now divided into two general categories:

HF with reduced ejection fraction (HFrEF)
(previously systolic HF)

HF with preserved ejection fraction (HFpEF)
(previously diastolic HF)

• Ejection fraction ≤ 40%
• Impaired myocardial

• Ejection fraction ≥ 50%
• Impaired myocardial relaxation

The prevention of HF and/or its progression necessitates an awareness and a response to risk factors of HF. Risk factors for HF include:

• Coronary artery disease (e.g., history of a myocardial infarction)
• Uncontrolled high blood pressure
• Diabetes
• Valvular heart disease (e.g., mitral regurgitation)
• Smoking tobacco
• Alcohol or illicit drug abuse
• Sedentary lifestyle
• Obesity

Efforts to address or minimize these risk factors (e.g., smoking cessation, adequate blood pressure control) should be prioritized as they can have a dramatic impact on the development and/or progression of HF. High blood pressure is considered “the most common cause of HF in older women, particularly in those with preserved ejection fraction.” For men, coronary artery disease is considered the most common cause.

Additionally, several medications have been associated with causing or exacerbating HF symptoms. Some of these medications are outlined in the following table. Mechanisms by which these medications may contribute to HF symptoms include direct myocardial toxicity,
negative inotropic effects (i.e., weakening the force of the heartbeat), worsening blood pressure control, or increasing sodium load. Key strategies in managing HF include being aware of medications that can negatively impact patients with HF and avoiding their use whenever possible.

Potential Mechanism


Retention of sodium and water

Negative inotrope

Other causes

Example Medications (not all-inclusive)

clozapine, cyclophosphamide, doxorubicin

alendronate effervescent, nonsteroidal anti-inflammatory drugs (e.g., ibuprofen)

diltiazem, disopyramide, dronedarone, flecainide, itraconazole, topical beta-blockers (e.g., timolol), verapamil


amphotericin B, doxazosin, pioglitazone, prazosin, rosiglitazone, saxagliptin, sitagliptin, terazosin

While pharmacological treatment is beyond the scope of this month’s article, it must be realized that early recognition of HF symptoms allows for earlier intervention and can hopefully avoid hospitalizations. The most common symptoms of HF include shortness of breath (especially during activity or when lying down), swelling, weakness, and fatigue. However, nursing facility staff should be vigilant for any of the following signs and symptoms suggestive of worsening HF: 

• peripheral edema and/or unexpected weight gain
• shortness of breath (SOB)/dyspnea
• rales (“crackles”)
• tachycardia
• elevated jugular venous pressure
• cool extremities
• cognitive changes/confusion

If noted, any of these signs and symptoms should be promptly reported to the prescriber to determine the appropriate next steps.

The prevalence of HF among skilled
nursing facility residents has been
estimated between 20% and 37.4%.

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