What is the American College of Cardiology (ACC) classification for heart failure?

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Last updated: October 22, 2026 • View editorial policy

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ACC Classification for Heart Failure

The ACC/AHA classification system divides heart failure into four progressive stages (A through D) based on structural heart disease and symptoms, designed to emphasize prevention and early intervention before symptomatic heart failure develops. 1, 2, 3

The Four Stages

Stage A: At Risk for Heart Failure

  • No structural heart disease and no symptoms
  • Patients with risk factors that predispose to heart failure:
    • Hypertension
    • Coronary artery disease
    • Diabetes mellitus
    • Obesity or metabolic syndrome
    • Exposure to cardiotoxic agents
    • Family history of cardiomyopathy or genetic variants
    • Atherosclerotic disease

Treatment focus: Aggressive risk factor modification, including management of hypertension and hyperlipidemia 4, 1

Stage B: Pre-Heart Failure (Structural Heart Disease Without Symptoms)

  • Structural heart disease present but no current or past HF symptoms
  • Includes patients with:
    • Previous myocardial infarction
    • Left ventricular hypertrophy (LVH)
    • Reduced ejection fraction without symptoms
    • Asymptomatic valvular disease
    • Left ventricular remodeling
    • Evidence of increased filling pressures (by invasive or noninvasive measures)
    • Elevated natriuretic peptides or persistently elevated cardiac troponin (in absence of competing diagnoses like acute coronary syndrome, chronic kidney disease, or pulmonary embolus) 3

Treatment focus: ACE inhibitors or ARBs and beta-blockers in all patients with reduced ejection fraction to prevent progression to symptomatic HF 4, 1

Stage C: Symptomatic Heart Failure

  • Structural heart disease with current or past symptoms of HF
  • This encompasses the majority of heart failure patients
  • Includes patients with:
    • Known structural heart disease
    • Shortness of breath and fatigue
    • Reduced exercise tolerance
    • Recurrent HF symptoms

Treatment focus: ACE inhibitors, beta-blockers, and diuretics for fluid retention; aldosterone antagonists and additional therapies as indicated 4, 1

Stage D: Advanced/Refractory Heart Failure

  • Marked symptoms at rest despite maximal medical therapy
  • Patients requiring specialized interventions:
    • Mechanical circulatory support
    • Continuous intravenous inotropic infusions
    • Cardiac transplantation evaluation
    • Procedures to facilitate fluid removal
    • Hospice/end-of-life care
  • Recurrent hospitalizations despite guideline-directed medical therapy optimization 1, 3

Key Distinguishing Features of the ACC/AHA Staging System

This classification is fundamentally different from the NYHA functional classification in several critical ways:

  • Progression is unidirectional: Patients advance from one stage to the next and cannot regress to earlier stages (e.g., a Stage C patient who becomes asymptomatic remains Stage C, not Stage B) 2
  • Emphasizes prevention: Stages A and B identify at-risk patients before symptoms develop, enabling early intervention 1
  • Treatment-specific: Each stage has distinct therapeutic interventions linked to reducing morbidity and mortality 1
  • Complements NYHA: The ACC/AHA staging works alongside (not replacing) NYHA functional classes I-IV, which assess symptom severity 2

Important Clinical Considerations

The 2022 ACC/AHA/HFSA guideline update expanded Stage B criteria, particularly by including patients with elevated natriuretic peptides or persistently elevated cardiac troponin even without structural abnormalities on imaging 3. This resulted in a substantial shift of individuals from Stage A to Stage B in community populations (from 15.9% to 43.2%), disproportionately affecting women, Hispanic, and Black individuals 5. Despite this broader definition, Stage B patients remain at significantly elevated risk for progression to symptomatic HF (HR: 10.61) 5.

Common pitfall: Do not confuse ACC/AHA stages with NYHA classes. A Stage C patient can be NYHA Class I (asymptomatic on therapy) but still requires Stage C treatments because they have had symptomatic HF in the past 2.

Practical application: The staging system recognizes that heart failure, like cancer, has established risk factors and structural prerequisites, and that specific treatments at each stage can reduce disease progression and mortality 1, 2.

The most recent comprehensive update defining these stages appears in the 2022 ACC/AHA/HFSA guideline 3, with the staging concept originally introduced in 2001 and refined in subsequent updates 1, 2.

References

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