New York Association classification of heart failure

Last reviewed 10/2019

New York Heart Association (NYHA) classification is used to grade the severity of functional limitations in a patient with heart failure (1):

  • class I no limitation of physical activity
    • ordinary physical activity does not cause fatigue, breathlessness or palpitation (includes asymptomatic left ventricular dysfunction)

  • class II slight limitation of physical activity
    • patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, breathlessness or angina pectoris (symptomatically 'mild' heart failure)

  • class III marked limitation of physical activity
    • although patients are comfortable at rest, less than ordinary activity will lead to symptoms (symptomatically 'moderate' heart failure)

  • class IV inability to carry out any physical activity without discomfort
    • symptoms of congestive cardiac failure are present even at rest. Increased discomfort with any physical activity (symptomatically 'severe' heart failure)

According to a study conducted, the following criteria were used by cardiologists to determine the NYHA class of a patient (cardiologists could use multiple criteria for assessment):

  • self reported walking distance - 70%
  • difficulty in climbing stairs - 60%
  • ability to walk to local landmarks - 30%
  • breathlessness interferes with daily activities - 23%
  • breathless when walking around the house - 23%
  • no specific questions - 13% (1)

This study has also pointed out that NYHA classification system is subjective and poorly reproducible since there are no clear standard criteria for assigning an NYHA class (1).


  • the functional class tends to deteriorate unevenly overtime, so the severity of the symptoms cannot be compared with the severity of the underlying problem e.g. – patients with severe disease may have mild symptoms and vice versa
  • favourable or adverse effects on functional capacity can occur with changes in medication and diet in the absence of any measurable changes in heart function (3)