Is cardiac remodeling with cardiac valve dysfunction, even if trivial, and adequate Ejection Fraction (EF) considered stage B heart failure symptomatic?

Cardiac Remodeling with Valve Dysfunction and Preserved EF is Stage B Heart Failure

Cardiac remodeling with valve dysfunction, even if trivial, and adequate ejection fraction is classified as Stage B heart failure (pre-heart failure) according to the ACC/AHA heart failure staging system. 1

Understanding Heart Failure Staging

The ACC/AHA classifies heart failure into four stages:

• Stage A: At risk for heart failure but without structural heart disease or symptoms
• Stage B: Structural heart disease but without signs or symptoms of heart failure
• Stage C: Current or prior symptoms of heart failure
• Stage D: Advanced heart failure requiring specialized interventions

Why This is Stage B Heart Failure

Cardiac remodeling represents a structural change in the heart's geometry and function that occurs in response to injury or altered hemodynamics 2. The 2022 ACC/AHA guidelines clearly define Stage B as:

• Patients without current or previous symptoms/signs of heart failure but with evidence of:
  • Structural heart disease
  • Evidence of increased filling pressures
  • Risk factors and increased biomarkers 1

Key points supporting Stage B classification:

1. Structural abnormality: Cardiac remodeling represents a change in chamber size, geometry, and structure of the heart 1
2. Valve dysfunction: Any valve dysfunction, even if trivial, represents a structural cardiac abnormality 1
3. Preserved EF: The presence of normal ejection fraction does not exclude Stage B heart failure - structural abnormalities can exist with preserved EF 1

Clinical Implications

Stage B heart failure is considered "pre-heart failure" - a critical point for intervention before symptoms develop. Patients with cardiac remodeling and valve dysfunction are at risk for progression to symptomatic heart failure (Stage C) 1.

Management Considerations:

• Medical therapy: Consider GDMT including ACE inhibitors/ARBs/ARNIs, beta-blockers, and MRAs to prevent progression 3, 2
• Regular monitoring: Serial assessment of cardiac structure and function is reasonable in patients with Stage B heart failure 1
• Risk factor control: Aggressive management of hypertension, diabetes, and other cardiovascular risk factors 1
• Valve assessment: Regular monitoring of valve dysfunction, even if trivial 1

Important Distinctions

• Asymptomatic vs. Symptomatic: By definition, Stage B heart failure is asymptomatic. If symptoms develop, the patient progresses to Stage C 1
• Preserved EF Classification: While the patient has adequate EF, they would be classified as having HFpEF (Heart Failure with preserved Ejection Fraction, EF ≥50%) if they develop symptoms 1

Caveat

Cardiac remodeling with valve dysfunction represents a progressive disorder that often precedes symptom development by months or years 1. Early intervention in Stage B heart failure is crucial to prevent progression to symptomatic stages and improve long-term outcomes 2, 4.