Skip Navigation

European Journal of Heart Failure 2001 3(6):739-746; doi:10.1016/S1388-9842(01)00206-9
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (8)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Gibelin, P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Gibelin, P.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© 2001 European Society of Cardiology

An evaluation of symptom classification systems used for the assessment of patients with heart failure in France

P. Gibelin*

Cardiology Department, Hôpital Pasteur, Nice University Hospital Group-BP 69 06002 Nice Cedex 1, France


   Abstract
Top
 Notes
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Many systems have been proposed to assess the degree of functional impairment in patients with chronic heart failure in order to be able to draw comparisons between patients and assess the development of the disease in the same patient. The NYHA classification is subjective and insufficiently reproducible and has no real predictive value with respect to the exertion test. The Canadian classification does not contribute much in terms of validation. The Feinstein and Duke University classifications are too complex, not very easy to use and have never been validated. The scale of activity proposed by Goldman gives details on functional impairment by using examples from daily activities, selected for their variety and grouped according to the energy that they require. This classification is highly reproducible and is concordant with the exertion test (duration of the exertion test, VO2 max). However, it is not suitable for France. The examples are not precise enough: in addition, they do not eliminate contradictions that can make the patient impossible to classify. We propose a scale of activity specifically designed for use in France. It is reproducible and the VO2 peaks are highly concordant. Lastly, the questions the patient is asked are progressive, thus avoiding contradictory answers. This classification could prove to be useful in everyday life and also for multi-center studies in French-speaking countries.

Key Words: Chronic heart failure • NYHA classification • Validation • France

Received June 26, 2000; Revised February 2, 2001; Accepted April 26, 2001


   1. Introduction
Top
 Notes
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Patients with heart failure are usually assessed for the severity of functional impairment on the basis of their answers to a questionnaire.

In 80% of the cases, patients consult for subjective symptoms. The two main signs researched are dyspnea and fatigue.

Dyspnea after exertion must be measured to assess the degree of impairment and monitor the development of the disease.

To assess impairment, a thorough case history of the patient must be taken; it is important that the questionnaire should be based on questions that supply information that is reproducible for the same patient or between patients.

Many systems have been proposed to evaluate the degree of functional impairment, to perform inter-patient comparisons or to assess the development of the disease.

The functional classification must be simple so that it can be used in routine clinical practice, but it must also be precise so that it can be included in scientific studies to compare drugs or for the purpose of epidemiological studies. The most widely used classification is the NYHA classification (Table 1).


View this table:
[in this window]
[in a new window]

  		Table 1 New York Heart Association functional classification

 
In this classification, the patients are divided into four classes according to the degree of symptoms they experience as a result of the physical activity related to every day life or to any other minor activity.

The advantages of this classification have contributed to its success. Above all, it is simple to use in routine practice, has been in use for a long period and is included in most of the studies published on heart failure. Although it has been criticized by many, there is no doubt that it has withstood the test of time.

However, this classification does have a number of drawbacks. First of all, it is subjective. The concept of activity related to every day life varies according to age, gender, habits, and more particularly, professional activity.

Another factor of subjectivity is related to the physician and his or her interpretation of the degree of exertion. Also, the questions vary from one physician to another, despite the fact that they should be sufficiently stereotyped for use by any physician.

The NYHA classification is not easily reproducible. According to a study carried out by Goldman et al. [1], the opinion of two independent observers is concordant in only 56% of cases; a discrepancy of one class was recorded in 37% of cases, two classes in 5% and 3 classes in 1% of the cases. The discrepancies occur mainly in classes II and III.

The NYHA classification predicts the exertion capacity assessed on the basis of the duration of the test in only 16 of 44 patients in Franciosa's study [2], i.e. 36% of the cases. Patterson [3] obtained a predictive value of 74% with two independent observers. Goldman's study records the concordance between the duration of the exertion test and the NYHA in only 51% of cases (77 patients) in a series of 150 and discordance of one, two or three classes in respectively 42%, 5% and 1% of cases.

Thus, this classification does not offer good predictive value of tolerance to the exertion test assessed on the basis of the duration of exertion.

The same results are found if the exertion capacity is assessed using VO2 max.

In a study carried out in the Cardiology Department at the Nice University Hospital [4] on a series of 32 patients with chronic heart failure, we did not find any correlation between the VO2 peak and the NYHA classification.

Cohen-Solal and al. [5] have shown that VO2 max has no predictive value in the NYHA; classes II and III group most patients together without sufficient discrimination.

Finally about prognosis; Califf et al. [6] have shown that only class IV had a prognosis value.

1.1. The Canadian classification
The Canadian classification [7] established by the Canadian Cardiovascular Society proposed much more detailed criteria. It has been used in many multi-center studies [8] (Table 2).


View this table:
[in this window]
[in a new window]

  		Table 2 Canadian Cardiovascular Society functional classification

 
According to Goldman's study [1], this classification is more reproducible than the NYHA, with a concordant opinion between two observers in 73% of cases, a discrepancy of one class in 24% and of two and three classes in 1% of cases.

With respect to its validity in relation to the exertion test, it is more concordant than the NYHA, but the difference is not significant: in 59% of the cases the classes fit, in 36% they differ by one class, in 4% they differ by two classes and in 1% by three classes.

Lastly, both the Canadian classification and the NYHA tend to underestimate the evaluation when compared to the classification based on exertion.

1.2. Feinstein's classification
This is a dyspnea-fatigue index [9] (Table 3).


View this table:
[in this window]
[in a new window]

  		Table 3 Feinstein classification: the ratings for three components of the dyspnea/fatigue index

 
The index is composed of three parts:
  • the type of activity the patient is capable of performing;
  • the speed at which it can be performed (climbing the stairs at normal speed, running or, on the contrary, walking very slowly); and
  • the impact of functional impairment on every day life and on professional activities.

This classification was designed to assess changes in treatment. It includes 12 classes instead of four and only records dyspnea and fatigue. It attempts to take into account the quality of life. The authors compare it to an Apgar score for heart failure.

However, it is too complex to be used in routine practice.

1.3. Duke University classification
The Medical Center at Duke University [10] has designed a self-administered questionnaire with 12 scales (Table 4).


View this table:
[in this window]
[in a new window]

  		Table 4 The Duke activity status index

 
The activities of each proposition were chosen to represent the major aspects of the patient's activity: movement, personal hygiene, housework, sexual activity, and leisure.

Each activity is scored as a metabolic cost in MET. Thus, at the end of the evaluation, the METS scores are added to calculate the DASI or Dukes Activity Status Index.

This classification is an intermediate stage, between the classification and the questionnaire.

It is used to assess functional capacity and quality of life.

Here again, it is too long and too complex to be used in routine practice and its use is, therefore, limited to drug trials.

1.4. Scale of specific activities
The scale of specific activities is a new way to approach patient evaluation (Table 5).


View this table:
[in this window]
[in a new window]

  		Table 5 Criteria for determination of the Specific Activity Scale functional class of Goldman

 
It is made up of a pre-established questionnaire, based on a series of precise questions which pertain to increasingly intense exertion in order to limit the degree of subjectivity by refining the questions during the interview. Also, the person who asks the questions takes down details of the degree of functional impairment by using examples of exertion in daily living which are picked out because they are varied and grouped according to the amount of energy required.

Goldman's specific activity scale [1] is the most widely known.

This scale is as reproducible as the Canadian classification: 73% of concordant opinions between two observers, 25% discrepancy of one class, 1% for two classes, 0% for three classes, but its concordance with the exertion test is much better with a rate of 68%, 27% discrepancy for one class, 5% for two classes and 0% for three classes.

The results are also identical when the patient is questioned by a person who is not a physician with a mean duration of the question session which is close to that required for the NYHA evaluation.

More recently, for a series of 36 patients with chronic heart failure, Lee et al. [11] recorded a rate of inter-observer reproducibility of 81% for the scale of specific activity, with figures as high as 90% when the questions were asked by physicians and 77% for non-physicians.

These authors recorded excellent correlation with VO2 max (R=0.75; P<0.0001). At the same time, the correlation with max heart rate was 0.51 (P<0.01), max systolic blood pressure at 0.38 (P<0.05) and max heart rate** productxsystolic blood pressure at 0.62 (P<0.0001).

However, it is difficult to use this scale in France because the questions are often not adapted to French lifestyle nor to the way French physicians question their patients.

We have, therefore, designed an activity scale that is specific to France (Table 6).


View this table:
[in this window]
[in a new window]

  		Table 6
 
In a preliminary prospective study [12], carried out in the Cardiology Department at the Hôpital Pasteur in Nice, this simple evaluation scale was proved to be significantly more reproducible and more valid than the NYHA.

In the first French multi-center study, carried out with the participation of 720 private cardiologists on a series of 2353 patients, this scale was judged to be more practical and as precise as the Duke University scale [13].

As a follow-up to these results, a prospective study was set up by the French Society of Cardiology's ‘Heart Failure and Cardiomyopathy Group’ to assess the special French scale of activity in comparison to the NYHA and Weber's classification, based on the VO2 peak [14] in patients with chronic heart failure [15].


   2. Methods
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 5. Conclusion
 References
 
2.1. Patient population
Eight hospital centers participated in the study: Paris (Bichat and Boucicaut), Nantes, Grenoble, Strasbourg, Lyon, Boulogne and Nice.

All the patients were assessed using the NYHA classification and the Special French Scale of Activity (SFSA).

Five centers did a double SFSA evaluation, performed either by two independent physicians or by a doctor and a nurse.

One hundred and twenty-four patients, mean age 61 years (102 males) with chronic heart failure were included: 72 had ischemia, 40 were idiopathic, 10 had high blood pressure and two had aortic insufficiency.

Eighty-two patients had a double SFSA evaluation: 40 patients were interviewed by two physicians and 42 by a doctor and a nurse.

The mean ejection fraction was 32±5%.

2.2. Data analysis
Based on our pre-testing we hoped to show a 20% increase in reproducibility and a 20% increase in validity using the SFSA. To detect such changes with a power of 80% (i.e. a β error of 20%) and an {alpha} error of 5%, reproducibility testing was estimated to require 75 patients and validity testing was estimated to require 40 patients.

The overall proportion of times that the functional class estimates were reproducible (percentage of patients assigned to the same functional class by both observers using the same system) and valid (percentage of functional class estimates that agreed with the exercise testing performance class) for each of the two functional classification systems was analyzed.

Simultaneous comparisons of the performance of both classification systems were analyzed using a chi-square ({chi}2) statistic with two degrees of freedom.

If the overall {chi}2 statistic was significant, 2x2 comparisons of one system with another were made by the Mantel–Haenszel matched analysis because the performance of the two classification systems was measured on a common set of patients, and in some instances, by the same investigator. Statistical significance was defined as P<0.05.


   3. Results
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 5. Conclusion
 References
 
Reproducibility showed that 87% of patients were classified in the same class in the group interviewed by two doctors and 71% in the doctor/nurse group (Table 7).


View this table:
[in this window]
[in a new window]

  		Table 7 Reproducibility for a series of 82 patients

 
When the results were validated in comparison to those of the exertion test, we found that 47% of the results were concordant with NYHA and Weber classes vs. 61% for SFSA (P<0.05) (Table 8).


View this table:
[in this window]
[in a new window]

  		Table 8 Validity in comparison to Weber's classification

 
Table 9 shows the distribution of patients against classes A, B, C and D of the Weber classification.


View this table:
[in this window]
[in a new window]

  		Table 9 Comparison Weber/NYHA/SFSA: study for each class

 
SFSA yields more concordant results for the first three classes, but only class C is significant: 56% of concordant results for SFSA against 32% for the NYHA class (P<0.05). However, the trend is reversed for more serious cases.


   4. Discussion
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
5. Conclusion
 References
 
All in all, to be valid, a classification system must be reproducible from one observer to another and must offer reasonably good correlation with a relatively objective scale, usually the exertion test with measurement of oxygen consumption. Of course, this examination is in itself, to a certain extent, subjective, because it depends on the motivation of the doctor and the patient.

The results of this study demonstrate that the SFSA is satisfactory in terms of its reproducibility between physicians or between a physician and a nurse. It can, therefore, easily be entrusted to a paramedic and can be done at the same time as the diet form is filled out, for example.

The SFSA test and the exertion test correlate significantly better than the NYHA and all the more so for classes II and III. This seems logical, keeping in mind that the lack of preciseness and homogeneity of the NYHA classification concerns mainly these two intermediate classes.

Therefore, the SFSA is good in terms of its reproducibility and better in its validity than NYHA.

Very recently, Briançon et al. proposed an approved translation of Goldman's specific activity scale [16].

The classification and two questionnaires on the quality of life were translated and counter-translated and then submitted to a Committee of Experts. The properties of the measurements of the three instruments were checked for validity on a sample of 74 patients with severe chronic heart failure (in hospital patients) and on 26 stable patients after heart transplant for reproducibility. The three instruments are valid and reproducible; but the validity of convergence with left ventricular ejection fraction and the NYHA measured during hospitalization for decompensation was poor.

In addition the validity of convergence in this study was not studied in ambulatory patient as well as the convergence with the exercise test.


   5. Conclusion
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
References
 
As the NYHA classification has its failings, other classifications have been proposed, particularly in heart failure.

Specific activity scales, based on a pre-established questionnaire composed of precise questions, each of which is matched to an increasingly marked degree of physical exertion are a new way to approach patient evaluation.

We have proposed the Special French Scale of Activity (SFSA) which, in our opinion, is more suited to the life style of French patients and to the way French doctors interview them.

In a multi-center study, the Heart Failure and Cardiomyopathy Group demonstrated improved reproducibility and validity of the SFSA in comparison to the NYHA reference classification.

There are, therefore, two ways to deal with the problems posed by the American classifications: either a very painstaking double-checked translation as used by the team from Nancy or a reproducible validated adapted classification, which can also be used by the paramedical staff, which was our group's choice.


   Notes
Top
 Notes
Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
* Tel.: +33-4-92-03-78-58; fax: +33-4-92-03-85-33. E-mail address: gibelinp{at}cote-dazur.com (P. Gibelin). Back


   References
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 

  1. Goldman L., Hashimoto B., Look F., Loscalzo A. Comparitive reproducibility and validity of systems for assessing cardiovascular functional class: advantages of a new specific activity scale. Circulation (1981) 64:1227–1234.[Abstract/Free Full Text]
  2. Franciosa J.A., Ziesche S., Wilen M. Functional capacity of patients with chronic left ventricular failure. Am J Med (1979) 67:460–466.[CrossRef][Web of Science][Medline]
  3. Patterson J.A., Naughton J., Pietra R.J., Gunnar R.M. Treadmill exercise in assessment of the functional capacity of patients with cardiac disease. Am J Cardiol (1972) 30:757–762.[CrossRef][Web of Science][Medline]
  4. Gibelin P., Rainart J.Ph., Aubran M., Camous J.P., Morand Ph. Intérêt d'un test ergonométrique pour évaluer l'insufficance cardiaque. Arch Mal Couer (1984) 77:1502–1509.
  5. Cohen-Solal A., Gourgon R. Mesure de la consommation d'oxygène à l'effort chez l'insuffisant cardiaque. Ann Cardiol Angéiol (1988) 37:601–608.
  6. Califf R.M., McKinnis R.A., Burks J., et al. Prognostic implications of ventricular arrhythmias during 24 hours ambulatory monitoring in patients undergoing cardiac catheterization for coronary artery disease. Am J Cardiol (1982) 50:23.[CrossRef][Web of Science][Medline]
  7. Campea L. Grading of angina pectoris. Circulation (1975) 54:522–523.
  8. Davis K., Kennedy J.W., Kenp H.G., Judkins M.P., Gosselin A.J., Killip T. Complications of coronary arteriography from the collaborative study of coronary artery surgery (CASS). Circulation (1979) 59:1105–1110.[Abstract/Free Full Text]
  9. Feinstein A.R., Fisher M.B., Pigeon J.G. Changes in dyspnea-fatigue ratings as indicators of quality of life in the treatment of congestive heart failure. AM J Cardiol (1989) 64:50–55.[CrossRef][Web of Science][Medline]
  10. Hlatky M.A., Boineau R.E., Higginbotham B., et al. A brief self-administered questionnary to determine functional capacity (The Duke Activity Status Index). Am J Cardiol (1989) 64:651–654.[CrossRef][Web of Science][Medline]
  11. Lee T.H., Shammash J.B., Ribeiro J.P., Hartley L.H., Sherwood J., Goldman L. Estimation of maximum oxygen uptake from clinical data: performance of the specific activity scale. Am Heart J (1988) 115:203–204.[CrossRef][Web of Science][Medline]
  12. Gibelin P., Dadoun-Dybal M., Morand P. Classification fonctionelle de l'insuffisance cardiaque. Arch Mal Couer (1993) 86(II):29–33.
  13. Gibelin P., Poncelet P., Gallois H., Sebaoin A., Avierinos C. et le Collège National des Cardiologues Français. Evaluation de trois classifications fonctionelles de l'insuffisance cardiaque: étude multicentrique nationale. Ann Cardiol Angéiol (1995) 44:304–309.
  14. Weber K.T., Janicki J.S. Cardiopulmonary exercise testing for evaluation of chronic cardiac failure. Am J Cardiol (1985) 55:22A–31A.[CrossRef][Medline]
  15. Gibelin P., Aumont M.C., Aupetit J.F., et al. Evaluation d'une échelle d'activité spécifique française de l'insuffisance cardiaque. Etude multicentrique nationale. Arch Mal Cœur (1999) 92:1175–1180.
  16. Briancon S., Alla F., Mejat E., et al. Mesure de l'incapacité fonctionelle et de la capacité de vie dans l'insuffisance cardiaque. Adaptation transculturelle et validation des questionnaire de Goldman, du Minesota et de Duke. Arch Mal Coeur (1997) 90:1577–1585.[Medline]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 Am. J. Respir. Crit. Care Med.Home page
O. Sitbon, C. Lascoux-Combe, J.-F. Delfraissy, P. G. Yeni, F. Raffi, D. De Zuttere, V. Gressin, P. Clerson, D. Sereni, and G. Simonneau
Prevalence of HIV-related Pulmonary Arterial Hypertension in the Current Antiretroviral Therapy Era
Am. J. Respir. Crit. Care Med., January 1, 2008; 177(1): 108 - 113.
[Abstract] [Full Text] [PDF]

Home page
 HeartHome page
A Verma, F Kilicaslan, D O Martin, S Minor, R Starling, N F Marrouche, S Almahammed, O M Wazni, S Duggal, R Zuzek, et al.
Preimplantation B-type natriuretic peptide concentration is an independent predictor of future appropriate implantable defibrillator therapies
Heart, February 1, 2006; 92(2): 190 - 195.
[Abstract] [Full Text] [PDF]

Home page
 NEJMHome page
M. Jessup and S. Brozena
Heart Failure
N. Engl. J. Med., May 15, 2003; 348(20): 2007 - 2018.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (8)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Gibelin, P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Gibelin, P.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?