Is it incorrect to think that a patient either has heart failure or doesn't, and that Stage A and B (American College of Cardiology/American Heart Association stages of heart failure) are just risk factors for developing symptomatic heart failure?

Your Thinking Is Partially Correct, But Misses the Critical Clinical Point

You are correct that Stages A and B are explicitly "not heart failure" according to ACC/AHA guidelines, but your thinking is wrong in dismissing them as merely risk factors—Stage B represents objective structural heart disease that requires specific evidence-based interventions to prevent mortality and progression to symptomatic heart failure. 1

The Guideline Position Is Explicit and Intentional

The ACC/AHA guidelines state unequivocally: "The first 2 stages (A and B) are clearly not HF but are an attempt to help healthcare providers with the early identification of patients who are at risk for developing HF." 1 So your semantic point is technically accurate—these patients do not have the clinical syndrome of heart failure.

However, the guidelines were deliberately designed this way to capture a critical therapeutic window:

• Stage A patients have risk factors only (hypertension, diabetes, coronary disease) without structural heart disease—these are indeed "just" risk factors 1
• Stage B patients have crossed a threshold: they have objective structural abnormalities (LV hypertrophy, impaired LV function, prior MI) but remain asymptomatic 1

Why Stage B Is Not "Just a Risk Factor"

The distinction matters because Stage B represents a point where the disease process has already begun and specific interventions reduce mortality:

• ACE inhibitors have Class I, Level A evidence for preventing symptomatic heart failure and reducing mortality in Stage B patients with LVEF ≤40% 2
• Beta-blockers have Class I, Level B-R evidence for preventing symptomatic heart failure in Stage B patients 2
• ICDs are indicated for Stage B patients ≥40 days post-MI with LVEF ≤30% for primary prevention of sudden cardiac death 2

These are not "risk reduction" strategies—these are mortality-reducing interventions for patients with established disease who happen to be asymptomatic.

The Staging System Is Deliberately Progressive and Irreversible

The ACC/AHA designed this system to mirror cancer staging, where patients advance through stages but cannot spontaneously regress. 1 This is fundamentally different from thinking about "risk factors":

• A Stage B patient with structural heart disease cannot return to Stage A even if asymptomatic 1
• A Stage C patient who becomes asymptomatic with treatment remains Stage C and requires continued Stage C therapies 1
• Progression is expected unless "slowed or stopped by treatment"—this is the entire therapeutic opportunity 1, 2

Where Your Thinking Goes Wrong

Your error is in conflating "heart failure as a clinical syndrome" with "heart failure as a disease process":

• Heart failure as a syndrome requires symptoms (dyspnea, fatigue, volume overload) 1—this only occurs in Stages C and D
• Heart failure as a disease process begins with structural cardiac abnormalities that will progress to the syndrome unless treated 1, 2

The ACC/AHA explicitly states: "Heart failure is not equivalent to cardiomyopathy or left ventricular dysfunction" 2, but they created the staging system precisely because waiting for symptoms before intervening misses the opportunity to prevent mortality.

The Clinical Imperative

Stage B is not a "pre-disease" state—it is established cardiac pathology requiring specific pharmacologic intervention. 2 The guidelines intentionally capture this stage because:

• Structural heart disease is objectively measurable (unlike NYHA class, which is subjective and fluctuates) 1
• Evidence-based therapies at this stage prevent progression and reduce mortality 2
• The staging system links specific treatments to specific disease stages 1

Common Pitfall to Avoid

Do not withhold ACE inhibitors, beta-blockers, or ICD therapy from asymptomatic patients with structural heart disease (Stage B) simply because they "don't have heart failure yet." 2 This thinking leads to preventable progression to symptomatic heart failure and preventable mortality. The evidence for intervention at Stage B is as strong as the evidence for treating Stage C patients.