What is the classification system for pediatric heart failure?

Pediatric Heart Failure Classification

The classification system for pediatric heart failure includes both the staging system (Stages A-D) similar to adults and age-specific functional classifications such as the modified Ross classification for children. 1, 2

Staging System for Pediatric Heart Failure

The American College of Cardiology/American Heart Association (ACC/AHA) heart failure staging system has been adapted for pediatric patients and includes:

• Stage A: At Risk for HF - Children at risk for heart failure but without symptoms, structural heart disease, or cardiac biomarkers of stretch or injury (e.g., patients with hypertension, exposure to cardiotoxic agents, genetic variant for cardiomyopathy, or positive family history of cardiomyopathy) 1

• Stage B: Pre-HF - No symptoms or signs of HF but evidence of:

  • Structural heart disease (reduced ventricular function, ventricular hypertrophy, chamber enlargement, wall motion abnormalities, valvular heart disease)
  • Increased filling pressures (by invasive hemodynamics or non-invasive imaging)
  • Elevated cardiac biomarkers (BNP, NT-proBNP, or cardiac troponin) 1

• Stage C: Symptomatic HF - Structural heart disease with current or previous symptoms of heart failure 1

• Stage D: Advanced HF - Marked heart failure symptoms that interfere with daily life and with recurrent hospitalizations despite attempts to optimize guideline-directed medical therapy 1

Functional Classification Systems for Pediatric Heart Failure

Modified Ross Classification

The modified Ross classification was specifically developed for children and provides a numeric score comparable to the NYHA classification used in adults 2, 3:

• Class I (Asymptomatic)

  • No limitations or symptoms
  • Normal growth and development 4, 3

• Class II (Mild HF)

  • Mild tachypnea or diaphoresis with feeding in infants
  • Dyspnea on moderate exertion in older children
  • Growth may be affected 4, 3

• Class III (Moderate HF)

  • Marked tachypnea or diaphoresis with feeding in infants
  • Prolonged feeding times with growth failure
  • Marked dyspnea on minimal exertion in older children 4, 3

• Class IV (Severe HF)

  • Tachypnea, retractions, grunting, or diaphoresis at rest
  • Inability to feed, requiring gavage or parenteral nutrition
  • Symptoms such as dyspnea at rest 4, 3

Age-Stratified Approach

Recent evidence suggests that an age-stratified approach to the Ross classification is more appropriate since infants and older children manifest heart failure differently 3:

• Infants (< 1 year): Focus on feeding difficulties, growth parameters, respiratory symptoms during feeding
• Toddlers/Young Children (1-6 years): Assess activity level, exercise tolerance, and feeding/growth
• Older Children (> 6 years): Can use NYHA-like criteria focused on exercise limitations 3

Clinical Presentation of Pediatric Heart Failure

The clinical presentation of heart failure in children includes:

• Respiratory symptoms: Tachypnea (>50 breaths/min in children <2 years, >40 breaths/min in children >2 years), retractions 1
• Cardiovascular signs: Sinus tachycardia, hepatomegaly, poor peripheral perfusion 1
• Feeding difficulties: Poor feeding, prolonged feeding times, failure to thrive 4
• Other signs: Diaphoresis, especially during feeding in infants 1

Important Considerations

• Unlike adults, the most common cause of heart failure in children is congenital heart disease, particularly ventricular septal defects, where myocardial function may be normal but excessive pulmonary blood flow leads to pulmonary edema 1

• The modified Ross score has been shown to have high sensitivity and specificity (100% with cutoff value of 2) for identifying heart failure in children with severe lower respiratory tract infections 2

• Assessment should include evaluation of structural abnormalities, ventricular function, and hemodynamics through echocardiography and potentially cardiac catheterization 1

• Newer approaches incorporate biomarkers (BNP, NT-proBNP) and echocardiographic parameters into the classification system to improve risk stratification 3

• Proper classification is essential for guiding therapeutic interventions and determining prognosis in pediatric heart failure 5, 6