Clinical Implications of the New York Heart Association Classification

Abstract

BackgroundThe New York Heart Association (NYHA) classification has served as a fundamental tool for risk stratification of heart failure (HF) and determines clinical trial eligibility and candidacy for drugs and devices. However, its ability to adequately stratify risk is unclear.Methods and ResultsTo compare NYHA class with objective assessments and survival in patients with HF, we performed secondary analyses of 4 multicenter National Institutes of Health–funded HF clinical trials that included patients classified as NYHA class II or III: TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist), DIG (The Effect of Digoxin on Mortality and Morbidity in Patients With Heart Failure), HF‐ACTION (Efficacy and Safety of Exercise Training in Patients With Chronic Heart Failure), and GUIDE‐IT (Guiding Evidence‐Based Therapy Using Biomarker Intensified Treatment in Heart Failure). Twenty‐month cumulative survival was compared between classes using Kaplan–Meier curves and the log rank test. NT‐proBNP (N‐terminal pro–B‐type natriuretic peptide), Kansas City Cardiomyopathy Questionnaire (KCCQ) scores, 6‐minute walk distances, left ventricular ejection fraction, and cardiopulmonary test parameters were compared using Wilcoxon rank sum tests and percentage overlap using kernel density estimations. Cumulative mortality varied significantly across NYHA classes and HF clinical trials (likelihood ratio, P<0.001). Mortality at 20 months for NYHA class II ranged from 7% for patients in HF‐ACTION to 15% in GUIDE‐IT, whereas mortality for NYHA class III ranged from 12% in TOPCAT to 26% in GUIDE‐IT. There was substantial percentage overlap in values for NT‐proBNP levels (79% and 69%), KCCQ scores (63% and 54%), 6‐minute walk distances (63% and 54%), and left ventricular ejection fraction (88% and 83%). Similarly, there was substantial overall in values for minute ventilation–carbon dioxide production relationship (71%), maximal oxygen uptake (54%), and exercise duration (53%).ConclusionsThe NYHA system poorly discriminates HF patients across the spectrum of functional impairment. These findings raise important questions about the need for improved phenotyping of these patients to facilitate risk stratification and response to interventions.

Baseline factors identified for the prediction of good responders in patients with end-stage diffuse coronary artery disease undergoing intracoronary CD34+ cell therapy

“…In many clinical circumstances, LVEF is not consistent with the New York Heart Association functional class because the latter is namely dependent on patient's physiological adaptation, metabolic status, oxygen consumption, and myocardial oxygen balance determined by the ratio of oxygen supply to oxygen demand [26]. Therefore, besides N-terminal pro-brain natriuretic peptide level, LVEF, 6-min walk distances, and CPET, well-designed questionnaires are suggested for functional evaluation and risk stratification in HF patients [27].…”

Clinical significance of the long non‑coding RNA NEAT1/miR‑129‑5p axis in the diagnosis and prognosis for patients with chronic heart failure

“…The control subjects were obtained from a population of individuals referred for physical examination at Weifang People's Hospital (Weifang, China) during a same time period and were determined to not have any CHF. The patients with CHF had an LVEF <40% and were clinically stable, with the New York Heart Association (NYHA) stage ranging from II to IV based on the 1928 and 1994 revised version of NYHA staging system ( 16 ). The exclusion criteria for both the patients and controls were as follows: i) Presence of infection; ii) cancer; iii) history of surgery within 1 year; iv) history of cerebral vascular events within 6 months; v) heart assist devices; or vi) liver or renal failure.…”

Prioritizing symptom management in the treatment of chronic heart failure

“…Thus, the accurate assessment of dyspnoea is especially important due to its long‐term implications to hospitalization and prognosis.Dyspnoea is often ranked numerically or with ‘Likert’ scales based on how it impacts activities of daily living and thereby QoL 10,51 . The commonly utilized NYHA class has variable sensitivity in gauging dyspnoea and classifying patients 54 . Assessment of dyspnoea is challenging because patient activity level affects their sense and the impact of dyspnoea on QoL.…”