Stage B Heart Failure Diagnostic Criteria and Management

Definition and Diagnostic Criteria

The American College of Cardiology defines Stage B heart failure as structural heart disease without current or previous symptoms or signs of heart failure, with evidence of at least one of the following: reduced left or right ventricular systolic function, reduced ejection fraction or reduced strain, ventricular hypertrophy, chamber enlargement, wall motion abnormalities, or valvular heart disease 1, 2, 3
The American Heart Association recommends that patients with Stage B heart failure have no current or previous symptoms or signs of heart failure, and evidence of increased filling pressures by invasive hemodynamic measurements or noninvasive imaging suggesting elevated filling pressures 1, 2

The American College of Cardiology recommends ACE inhibitors or ARBs in appropriate patients with a history of MI and reduced EF to prevent progression to symptomatic heart failure, with a strength of evidence classified as high 4
The American Heart Association recommends evidence-based beta blockers in patients with MI and reduced EF, with a strength of evidence classified as high 4
The American College of Cardiology recommends statins in patients with a history of MI to prevent heart failure, with a strength of evidence classified as high 4
The American Heart Association recommends blood pressure control according to published guidelines, with a strength of evidence classified as high 4

The 2022 ACC/AHA/HFSA guidelines expanded the definition of Stage B heart failure to include objective evidence of increased filling pressures and biomarker criteria, with a strength of evidence classified as high 1, 2

The American College of Cardiology recommends avoiding nondihydropyridine calcium channel blockers with negative inotropic effects in patients with low LVEF, as they may be harmful, with a strength of evidence classified as moderate 4
Regular monitoring of patients with Stage B heart failure is essential, as they remain at high risk for developing symptomatic heart failure, with a strength of evidence classified as high 3, 4

The American College of Cardiology, American Heart Association, and Heart Failure Society of America define Stage B heart failure as having structural heart disease without current or previous symptoms or signs of heart failure, with evidence of at least one of the following on echocardiography: reduced left ventricular systolic function, ventricular hypertrophy, chamber enlargement, wall motion abnormalities, or valvular heart disease is not directly cited, however left ventricular ejection fraction (LVEF) ≤40% (defining HFrEF) without symptoms is defined by the ACC 5

Left ventricular ejection fraction (LVEF) 41-49% (defining HFmrEF) without symptoms is defined by the ACC 5

Left ventricular hypertrophy (increased LV mass index) is defined by the ACC 5
Chamber enlargement (increased left atrial volume index and/or left ventricular dimensions) is defined by the ACC 5

Elevated E/e' ratio >9 on echocardiography (suggesting elevated LV filling pressures) is defined by the ACC 5
Echocardiographic pulmonary artery systolic pressure >35 mm Hg is defined by the ACC 5

Serial echocardiographic assessment is important as changes in LVEF might not be unidirectional; patients may experience improvement followed by decrease in EF or vice versa, as stated by the ACC 5
Trajectory of LVEF is important, and a significant reduction in LVEF over time is a poor prognostic factor, as stated by the ACC 5

The American College of Cardiology and American Heart Association define Stage B heart failure as structural heart disease without current or previous symptoms of heart failure, with patients having objective cardiac abnormalities but remaining asymptomatic, and distinguish it from Stage A and Stage C based on symptom history and structural changes 6
The American College of Cardiology and American Heart Association staging system is intentionally designed to be unidirectional, with patients advancing from one stage to the next unless disease progression is halted by treatment, and spontaneous reversal is considered unusual 6

Stage B represents a point where patients are at substantial risk for developing symptomatic heart failure and require aggressive evidence-based interventions to prevent progression, with the American College of Cardiology and American Heart Association emphasizing the importance of early intervention 6