Where is your heart (failure) in New York?

After diagnosing a patient with heart failure, cardiologists will usually classify symptoms into one of the four stages of heart failure based on the presence or absence and severity of structural heart disease/damage, as described below. It is simple but powerful assessment tool to guide them in developing the right medical treatment plan.

Stage/ Definition

Stage A

Presence of heart failure risk factors but no heart disease and no symptoms

Stage B

Heart disease is present but there are no symptoms (structural changes in heart before symptoms occur)

Stage C

Structural heart disease is present and symptoms have occurred

Stage D

Presence of advanced heart disease with continued heart failure symptoms requiring aggressive medical therapy

Source: The American College of Cardiology and the American Heart Association Stages of Heart Failure

Similarly, cardiologists will likely “classify” heart failure condition according to the severity of your symptoms. This classification system, known as the New York Heart Association (NYHA) Functional Classification, places you into one of four categories based on your physical activity limitations.

Class/ Patient Symptoms

Class I

No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation (feeling heart beats), or dyspnea (shortness of breath).

Class II (Mild)

Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.

Class III (Moderate)

Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.

Class IV (Severe)

Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

Patients with heart failure are usually treated with a combination of medications, depending on their symptoms. Loop diuretics (water pills) to relieve symptoms and signs of congestion or volume overload. Angiotensin-converting enzyme (ACE) inhibitors, the current first-line treatment, widen blood vessels to lower blood pressure, improve blood flow and decrease the workload on the heart.

Angiotensin II receptor blockers (ARBs) provide many of the same benefits of ACE inhibitors and may be an alternative for people who cannot tolerate ACE inhibitors. Beta-blockers and If channel inhibitor can effectively control the heart rate, increase diastolic filling time and improve coronary perfusion.

Mineralocorticoid receptor antagonists (MRA) prevent endothelial dysfunction, and vascular and cardiorenal adverse remodeling related with progression in congestive heart failure. And the old but reliable digoxin which increases the strength of heart muscle contractions, slows heartbeat and reduces symptoms; it is usually given to patients with abnormally fast and irregular heart rhythm (arrhythmia), such as atrial fibrillation.

A new class of medication for heart failure has recently become available in the Philippines. Sacubitril/valsartan is the first-in-class angiotensin receptor-neprilysin inhibitor (ARNI). The twice-daily pill is indicated for patients with heart failure with reduced ejection fraction (HF-rEF) and classified NYHA class II to IV.

The efficacy and safety of sacubitril/valsartan is supported by robust evidence. The PARADIGM-HF Trial, the largest heart failure trial ever conducted, showed that patients with HF-rEF who were given sacubitril/valsartan were more likely to be alive and less likely to have been hospitalized for sudden deterioration of their heart failure than those given the ACE inhibitor enalapril.

There is a high unmet need for new heart failure treatments. The availability of a novel, proven-effective treatment for heart failure is welcome news as this novel treatment can improve the quality of life and survival of Filipino patients suffering from this chronic debilitating and life-threatening condition.

Dr. Raul L. Lapitan, president of the Philippine Heart Association 2016-2017, completed his medical degree at the Far Eastern University-Dr. Nicanor Reyes Medical Foundation Institute of Medicine and finished his Fellowship in Cardiology at the Makati Medical Center. The PHA is an organization of cardiovascular specialists and lay members that ensure accessible, affordable and quality cardiovascular education and care for everyone. For more information, visit www.philheart.org.