Clinical implications of the New York Heart Association classification
Open accessAbstract
Background The New York Heart Association ( NYHA ) classification has served as a fundamental tool for risk stratification of heart failure ( HF ) and determines clinical trial eligibility and candidacy for drugs and devices. However, its ability to adequately stratify risk is unclear. Methods and Results To compare NYHA class with objective assessments and survival in patients with HF , we performed secondary analyses of 4 multicenter National Institutes of Health–funded HF clinical trials that included patients classified as NYHA class II or III: TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist), DIG (The Effect of Digoxin on Mortality and Morbidity in Patients With Heart Failure), HF‐ACTION (Efficacy and Safety of Exercise Training in Patients With Chronic Heart Failure), and GUIDE‐IT (Guiding Evidence‐Based Therapy Using Biomarker Intensified Treatment in Heart Failure). Twenty‐month cumulative survival was compared between classes using Kaplan–Meier curves and the log rank test. NT ‐proBNP (N‐terminal pro–B‐type natriuretic peptide), Kansas City Cardiomyopathy Questionnaire ( KCCQ ) scores, 6‐minute walk distances, left ventricular ejection fraction, and cardiopulmonary test parameters were compared using Wilcoxon rank sum tests and percentage overlap using kernel density estimations. Cumulative mortality varied significantly across NYHA classes and HF clinical trials (likelihood ratio, P <0.001). Mortality at 20 months for NYHA class II ranged from 7% for patients in HF ‐ ACTION to 15% in GUIDE ‐ IT , whereas mortality for NYHA class III ranged from 12% in TOPCAT to 26% in GUIDE ‐ IT . There was substantial percentage overlap in values for NT ‐pro BNP levels (79% and 69%), KCCQ scores (63% and 54%), 6‐minute walk distances (63% and 54%), and left ventricular ejection fraction (88% and 83%). Similarly, there was substantial overall in values for minute ventilation–carbon dioxide production relationship (71%), maximal oxygen uptake (54%), and exercise duration (53%). Conclusions The NYHA system poorly discriminates HF patients across the spectrum of functional impairment. These findings raise important questions about the need for improved phenotyping of these patients to facilitate risk stratification and response to interventions.
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The commonly utilized NYHA class has variable sensitivity in gauging dyspnoea and classifying patients.
“The commonly utilized NYHA class has variable sensitivity in gauging dyspnoea and classifying patients. 54”
From Prioritizing symptom management in the treatment of chronic heart failure (2020) · cites this paper as [54]
The Introduction describes NYHA classification as widely used but subjective and poorly reproducible. The Results and Discussion find substantial overlap between classes II and III on measures of functional impairment, supporting the concern about how well it classifies heart-failure patients. Our copy does not assess sensitivity specifically for gauging dyspnoea. (LLM, conf=0.84)
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- Authors
- Caraballo, C., Desai, N. R., Mulder, H., Alhanti, B., Wilson, F. P., Fiuzat, M., Felker, G. M., Piña, I. L., O'Connor, C. M., Lindenfeld, J., Januzzi, J. L., Cohen, L. S., & Ahmad, T.
- Affiliations
- Yale University (US)
- Duke Clinical Research Institute (US)
- Detroit Medical Center (US)
- Inova Heart and Vascular Institute Fairfax VA
- Vanderbilt University Medical Center (US)
- Massachusetts General Hospital (US)
- Corresponding author
- Ahmad, Tariq
- ORCID
- Venue
- Journal of the American Heart Association
- Published
- 2019-12-03
- Volume
- 8
- Issue
- 23
- Pages
- e014240-e014240
- ISSN
- 2047-9980 (ISSN-L)
- PMC
- PMC6912957
- OpenAlex
- W2991004728
- Cited by
- 351
- References
- 14
- Citations by year
- 2026: 48 · 2025: 76 · 2024: 65 · 2023: 74 · 2022: 43 · 2021: 34 · 2020: 10
- FWCI
- 15.73
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by-nc
- Locations
- Journal of the American Heart Association (publishedVersion, cc-by-nc)
- Europe PMC (PubMed Central) (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Funders
- National Institutes of Health (UL1TR001863)
- National Institute of Diabetes and Digestive and Kidney Diseases (P30DK079310)
- National Center for Advancing Translational Sciences
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Failure Treatment and Management
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart rate and cardiovascular health
- Health Sciences › Medicine › Complementary and alternative medicine › Cardiovascular and exercise physiology
- Keywords
- NYHA functional class, heart failure, risk stratification, mortality, NT-proBNP, Kansas City Cardiomyopathy Questionnaire, 6-minute walk distance, left ventricular ejection fraction, exercise capacity, patient phenotyping, TOPCAT, dig
- MeSH terms
- Heart Failure, Humans, New York, Societies, Medical, Risk Assessment
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