NYHA Class II Heart Disease
This patient's symptoms clearly indicate NYHA Class II heart disease. She is comfortable at rest but ordinary physical activity (making the bed, gathering laundry) causes fatigue, chest pain, and tachycardia—the defining characteristics of Class II functional limitation 1.
Clinical Classification Rationale
The NYHA classification system defines Class II as: patients with cardiac disease resulting in slight limitation of physical activity who are comfortable at rest, but for whom ordinary physical activity results in fatigue, palpitation, or dyspnea 1.
This patient demonstrates all the cardinal features:
- Comfortable at rest: She has no symptoms when sitting quietly 1
- Slight limitation with ordinary activity: Tasks like bed-making and laundry gathering trigger symptoms 1
- Specific symptoms provoked: Chest pain (anginal equivalent), tachycardia (palpitations), and persistent fatigue 1
Why Not Other NYHA Classes?
Class I is excluded because she clearly has functional limitations—she had to stop working at 20 weeks gestation due to persistent fatigue, and ordinary household activities provoke symptoms 1. Class I patients perform ordinary physical activity without undue symptoms 1.
Class III is excluded because her symptoms require ordinary (not less-than-ordinary) activity to manifest 1. Class III patients experience marked limitation where even minimal exertion causes symptoms 1.
Class IV is excluded because she has no symptoms at rest 1. Class IV patients cannot carry on any physical activity without discomfort and may have symptoms even at rest 1.
Critical Context: Pregnancy and Rheumatic Heart Disease
This Class II designation carries significant prognostic weight in pregnancy. While most patients with NYHA Class I-II heart disease have successful pregnancies, rheumatic heart disease (particularly mitral stenosis) can deteriorate even from asymptomatic states due to pregnancy's hemodynamic burden 1, 2.
Key physiologic stressors at 30 weeks gestation:
- Cardiac output increases 30-50% above baseline, peaking at 24-32 weeks 2
- Plasma volume expands by 40% 2
- These changes force increased flow across stenotic valves, sharply elevating transvalvular gradients and left atrial pressure 2
High-risk indicators present in this case:
- Had to stop working at 20 weeks—suggesting inadequate cardiovascular reserve 1
- Persistent fatigue despite rest—a warning sign of decompensation 2, 3
- Symptoms with ordinary activity at 30 weeks—the peak hemodynamic stress period 2
Management Implications
This patient requires urgent multidisciplinary evaluation at a specialized center 2, 3. The European Society of Cardiology emphasizes that rheumatic heart disease in pregnancy, even in NYHA Class II, demands expert cardio-obstetric team management because:
- Risk escalates rapidly in the third trimester and peripartum period 1, 2
- Mitral stenosis is particularly poorly tolerated as increased cardiac output causes sharp rises in pulmonary pressures 2
- The postpartum period represents a second critical high-risk window with major hemodynamic shifts 2
Immediate diagnostic priorities:
- Echocardiography to assess valve severity, particularly mitral valve area and pulmonary artery pressures 2, 3
- Evaluation for pulmonary hypertension (mean PA pressure ≥25 mmHg), which carries 17-50% maternal mortality 3
Common Pitfall to Avoid
Do not dismiss symptoms as "normal pregnancy fatigue." Rheumatic heart disease is now rare in Western countries except in immigrants, and dyspnea may be wrongly attributed to normal pregnancy or asthma rather than cardiac decompensation 1, 2. This patient's need to stop working and symptoms with ordinary activity are red flags requiring cardiac evaluation, not reassurance 2, 3.