Classes of Heart Failure

Is there a way to know how advanced your heart failure is?  The answer is yes and yes.  The British website “Heart Failure Matters” advises that there are two systems used for grading heart failure and it is likely that your doctor will use a combination of both to assess the extent of the damage to your heart.    
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I looked at several websites to find the simplest explanation of the two systems, and why doctors may use both to provide to provide an assessment.  The Mayo Clinic provided the following explanation:

• New York Heart Association classification. This symptom-based scale classifies heart failure in four categories. In Class I heart failure, you don't have any symptoms. In Class II heart failure, you can perform everyday activities without difficulty but become winded or fatigued when you exert yourself. With Class III, you'll have trouble completing everyday activities, and Class IV is the most severe, and you're short of breath even at rest.
• American College of Cardiology/American Heart Association guidelines. This stage-based classification system uses letters A to D.  For example, a person who has several risk factors for heart failure but no signs or symptoms of heart failure is Stage A.  A person who has heart disease but no signs or symptoms of heart failure is Stage B. Someone who has heart disease and is experiencing or has experienced signs or symptoms of heart failure is Stage C. A person with advanced heart failure requiring specialized treatments is Stage D.  Doctors use this classification system to identify your risk factors and begin early, more aggressive treatment to help prevent or delay heart failure.

With respect to the NYHA scale, the website Heart Healthy Women designates classes I and II as mild, Class III as moderate, and Class IV as Severe.

According to Pennmedicine.org, the ACC/AHA system does not replace, but complements the NYHA system.  The ACC/AHA guidelines actually identifies a patient class that is not included in the NYHA classification.  This would be the class A, the class of patients who do not have heart failure, but are at high risk for developing the condition.

The Pumping Marvellous webpage includes a Full Marvellous Guide to Heart Failure.  Don’t you love the title of this guide?  To me, it is energizing, because I cannot help but think that maybe there is an benefit to having heart failure and that I can become fully marvelous regardless of how weak my heart becomes.  The benefit to me would be that when my heart enlarged in a very bad way to help my heart pump, my already zany sense of humor grew in a very positive way to help me see the lighter, more optimistic side of heart failure.

Anyway - back to what Pumping Marvellous tells us about the NYHA scale.  Basically, we learn that the NYHA scale can be used to good advantage not only by the doctor but by the patient:  “The NYHA scale is usually used by Clinicians to assess you. However, as you are the only one who knows how you feel, it’s a great tool to help you explain to Clinicians what’s been going on whilst they aren’t there.”  It has never dawned on me that I have been using the NYHA scale as a tool.  But thinking back on doctor appointments, yes I have related to them issues that I may have noted in terms of fatigue and shortness of breath as I go through the various tasks in my life. 

Pumping Marvellous goes on to make the observation that people with heart failure have a certain amount of energy, like a battery.  In my case, the CRT device gives me battery backup, so I believe this is indeed an apt comparison.  The battery comparison is also important because it illustrates that it is the amount of energy in your heart's battery that helps you perform your daily activities. 

The battery comparison really resonates with me because as we have discussed many times in this blog, the amount of energy I now have will not let me do the fully monty of the activities I used to do.  So I have to identify in advance what I want to get done in a particular day, and then carefully plan each segment of my day so I can accomplish  my goals.  This is where the very organized, disciplined Melanie comes in handy!  Equally important, if I find that I may have overdone it on a day (yep – that happens), then I have to edit out some stuff for a short time going forward to just recharge my natural batteries.  (This is where the very organized, Type A and perfectionist Melanie can sometimes freak out.  But she is learning to just suck it up).

And so you might ask where do I stand when it comes to the NYHA class system for heart failure?  At least as of late December of 2017, one of my doctors told me that I am a well-compensated Class 2 patient.  I agree with that assessment.  I definitely have symptoms of heart failure, but I also can perform everyday activities with no problem.  Yes, I do get short of breath and fatigued when I exert myself too much.  But I have found that I can do quite a lot of exercise without tiring out.  

So does the fact that I score out as "mild" in terms of heart failure mean I can just thrown caution to the wind and over exert myself?  The answer is no.  Why - because that would be negligent, by which I mean a patient who sees the caliber of heart specialists I do and who has a significant cardiomyopathy needs to guard her heart.  Clearly the stamina level I possess now is not the same that I possessed over five years ago.  But thankfully the gratitude level I now possess is off the charts.    I take it as a blessing that I can still keep up a pretty good clip when I walk either outside or on the treadmill.  And while climbing up more than one flight of stairs at once can be a challenge, I am learning and constantly reminding myself) not to let that discourage me.  I want to stay well compensated and I modify my lifestyle and approach accordingly. 

I have also learned that the symptom of shortness of breath can sometimes lessen depending on the season of the year.  In cold weather when I am sucking in a lot of cold air and wind, walking up inclines or stairs is harder, just as walking up an incline or stairs can really suck on a hot and humid day.  I think it is because the air and extreme temperature makes a harder workload for the heart.  (I promise to explain more about this in a future post).  But I can still get around even though I may have to slow down. 

So yes, I have come to accept the fact that I am a class 2 patient who has mild heart failure, and this is a welcome change in attitude.  This same fact bummed me out about 3 years ago, when I let the low ejection fraction, the low blood pressure, the unexpected bouts of dizziness and the sudden water retention overcome me.  I would think to myself – how long can this lousy heart continue to let me do one of the things I love the most – get out and exercise?  Well the answer was this lousy heart has continued to provide enough stamina and energy for me to exercise, and to go on trips, and to meet my friends for lunch or dinner or coffee, and to engage in some volunteer activities – and to write this blog!  So I think that while the condition of this heart may dump me into the Class 2 category, the persistence of my heart and soul upgrades me to first class.

Because I had to have the help of a therapist to work my way to the point of acceptance, it has dawned on me that there should be another classification system that comes into play when you have heart failure.  I do not know if the medical profession sees a need, but I can guarantee you that a second scale could help to inspire hope in the psyche of a heart failure patient. 

It would be a scale that rates the emotional state of the heart failure patient.  We could call it the Heart and Soul Tenacity (HST) classification scale.  Unlike the NYHA, where lower numbers are better, with the HST classification system, it would be better to have a higher number.  This is because the scale would be measuring how well the patient is not only living with but also emotionally accepting their condition.  The better scores would reflect how a positive nature is helping a patient to pursue a life with purpose regardless of a heart with damage. 

For example, here is a proposed description of each class level:

• Class 1:  The patient is unable to accept the fact that the heart has weakened, and that he or she has become a heart failure patient.  As a result, the patient finds it impossible to attempt, much less achieve, compliance with the doctor’s instructions. 
• Class 2:  The patient realizes that he or she continues to feel miserable, and has decided to comply with the dietary, restrictions, fluid restrictions, medication advice and exercise advice.  The patient still is unable to accept that a weakened heart is the cause of this incredible fatigue (hey, I can hear my heart beat and it sounds pretty strong to me!)   But the patient is willing to follow doctor's orders for the very short term in the hope that a determined will and obsessive discipline will result in a reversal of the damage.
• Class 3: The patient realizes that heart failure is not going anywhere, and he or she might as well add heart failure to the holiday card recipient list.  The patient is becoming more disciplined in applying the dietary and fluid restrictions, taking medications on a regular schedule, and exercising appropriately.  But while the patient finally accepts the shortness of breath and fatigue as a fact of life for eternity, he or she is hesitant to investigate what may come next.
• Class 4:  The patient has become a model of compliance in living with heart failure.  The patient no longer is terrified about the possibility that the heart failure may worsen.  The patient has examined more advanced treatment options, understanding that every day he or she remains functional, even on a reduced level, is a gift that buys time for the creation of new procedures, medications and therapies that could bring a cure, or at least, a better life.

​I guess what I am trying to say is that healing has physical and psychological aspects.  I definitely have always had the discipline to apply all the treatment aspects to make my physical heart stronger.  I appreciate the NYHA scale that keeps me motivated to do my very best on the physical end. 

But I also know that each of us has limited amount of time on this earth.  Each day is an opportunity for me to show that I am worthy of the life that God has breathed into me.  This is only possible when I am not scared of life, but am able to look my heart failure in the eye and not blink first.  I also need to make my heart failure my ally and figure how to accrue the level of physical and psychological stamina that will allow me to bestow gifts on my fellow humans.  The best gift I can currently imagine is to be a witness to the power and potential that religious faith can provide those who are undergoing powerful, sometimes devastating challenges.