1NYHA functional classification categories are as follows: Class I: patients with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain; Class II: patients with cardiac disease resulting in slight limitation of physical activity. Patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain; Class III: patients with marked limitation of physical activity. Patients are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain; Class IV: patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased. Valid, reliable, disease-specific patient-reported questionnaires include the Kansas City Cardiomyopathy Questionnaire (KCCQ); Minnesota Living with Heart Failure Questionnaire (MLHFQ); and Chronic Heart Failure Questionnaire (CHFQ).
2Patient symptoms have demonstrated clinically important deterioration since last assessment.
3A documented plan of care may include ≥1 of the following: reevaluation of medical therapy, including uptitration of doses, consideration of electrical device therapy, recommended lifestyle modifications (e.g., salt restriction, exercise training), initiation of palliative care, referral for more advanced therapies (e.g., transplant, ventricular assist device), or referral to disease management programs.
4Counseling should be specific to each individual patient and include documentation of a discussion regarding the risk of sudden and nonsudden death AND the efficacy, safety, and risks of an ICD. This will allow patients to be informed of the risks and benefits of ICD implantation and to be better able to make decisions based on the valuation of sudden cardiac death vs other risks.
5Must include ≥3 of the following elements: definition of heart failure (linking disease, symptoms, and treatment) and cause of patient's heart failure; recognition of escalating symptoms and concrete plan for response to particular symptoms; indications and use of each medication; modify risk for heart failure progression; specific diet recommendations; individualized low-sodium diet; recommendation for alcohol intake; specific activity/exercise recommendations; importance of treatment adherence and behavioral strategies to promote treatment adherence.