What are the four stages of systolic dysfunction in a patient with a left ventricular ejection fraction (LVEF) of 55-60%, mild sleep apnea, and impaired renal function, and how are they managed?

Four Stages of Systolic Dysfunction

The four stages of systolic dysfunction are defined by the ACC/AHA heart failure classification system: Stage A (at risk), Stage B (pre-heart failure with structural changes but no symptoms), Stage C (symptomatic heart failure), and Stage D (advanced heart failure requiring specialized interventions). 1, 2

Stage A: At Risk for Heart Failure

• Patients have risk factors for developing left ventricular dysfunction but no structural heart disease, symptoms, or elevated biomarkers 1, 2
• Risk factors include hypertension, diabetes, coronary artery disease, family history of cardiomyopathy, or exposure to cardiotoxic agents 1, 2
• Management focuses on aggressive risk factor modification: treating hypertension, controlling diabetes, lipid management, smoking cessation, and regular exercise 1
• No specific heart failure medications are indicated at this stage 1

Stage B: Pre-Heart Failure (Asymptomatic Structural Disease)

• Patients have structural heart disease or abnormal cardiac function without current or prior symptoms of heart failure 1, 2
• Evidence includes reduced LVEF, left ventricular hypertrophy, chamber dilation, wall motion abnormalities, or elevated natriuretic peptides 2
• In your patient with LVEF 55-60%, this would only apply if there were other structural abnormalities (e.g., significant hypertrophy, chamber dilation, or elevated filling pressures), as the LVEF itself is normal 3
• Treatment includes ACE inhibitors or ARBs and beta-blockers to prevent progression to symptomatic heart failure 1

Stage C: Symptomatic Heart Failure

• Patients have current or prior symptoms and/or signs of heart failure caused by structural and/or functional cardiac abnormality 2
• Symptoms include dyspnea, fatigue, reduced exercise tolerance, or fluid retention 1
• This stage is further classified by LVEF: HFrEF (LVEF ≤40%), HFmrEF (LVEF 41-49%), or HFpEF (LVEF ≥50%) 1, 2
• Your patient with LVEF 55-60% who develops symptoms would be classified as HFpEF (Stage C with preserved ejection fraction) 1, 3
• Management for HFpEF includes diuretics as needed for congestion, SGLT2 inhibitors (Class 2a recommendation), and consideration of ARNi, MRA, or ARB (all Class 2b recommendations, with greater benefit when LVEF is closer to 50%) 1

Stage D: Advanced Heart Failure

• Patients have severe symptoms and/or signs of heart failure at rest despite guideline-directed medical therapy 2
• Characterized by recurrent hospitalizations, refractory symptoms, or intolerance to standard therapies 2
• Requires consideration of advanced therapies: cardiac transplantation, mechanical circulatory support, continuous inotropic infusions, or palliative care 2
• One-year mortality can reach 25% in the most severe cases 1

Critical Context for Your Patient

With an LVEF of 55-60%, your patient has normal systolic function by standard criteria (normal LVEF is 50-70%, with >55% specifically defining normal function in multiple contexts) 3, 1

Important Considerations:

• The impaired renal function requires careful medication dosing and monitoring, particularly with ACE inhibitors, ARBs, or MRAs if heart failure develops 1
• Mild sleep apnea should be treated as it can contribute to hypertension, atrial arrhythmias, and progression of cardiac dysfunction 1
• If symptoms develop despite normal LVEF, consider diastolic dysfunction (HFpEF), which requires different diagnostic criteria including elevated filling pressures, elevated natriuretic peptides, or tissue Doppler evidence (E/E' >15) 4
• Serial LVEF measurements are more informative than a single value, as trajectory matters—declining LVEF even within the normal range may indicate early myocardial disease 3