ACC/AHA heart failure guidelines: Increase ICD use

The guidelines recognize the importance of triple therapy: ACE inhibitors, beta-blockers, spironolactone and/or aldosterone antagonists.

Patients with heart failure should be considered more often for treatement with implantable cardioverter defibrillators, according to new guidelines from the American College of Cardiology and the American Heart Association.

“The recommendation on ICD usage is huge. This essentially mirrors the Centers for Medicare and Medicaid Services guidelines for ICD implantation, which validate the CMS guidelines and will increase ICD usage.

“Heart failure specialists and electrophysiologists were already all over this, but now the general public will get the message,” said Douglas Mann, MD, chief of cardiology at Baylor College of Medicine and editorial board member of Cardiology Today’s Myocardial Disorders, Heart Failure and Transplantation section.

Douglas Mann

“We’ve known for a long time that as many as 40% of patients who have cardiomyopathy are going to die from ventricular dysrhythmias,” said Frank Smart, MD. “We’ve just never had any good therapy until ICDs.

“These new guidelines reflect what we learned in SCD-HeFT and MADIT,” said Smart, director of heart failure and cardiac transplantation at the Texas Heart Institute at St. Luke’s Hospital and also a member of the editorial board.

The ICD recommendations

The guidelines recommend an ICD for the secondary prevention of death from ventricular tachyarrhythmia in patients with otherwise good clinical function and prognosis. ICDs should also be considered in patients with chronic HF and low ejection fraction who experience syncope of unclear origin.

However, for secondary prevention, clinicians should avoid ICDs in patients with ventricular arrhythmias as well as a progressive and irreversible downward spiral of clinical HF decompensation. “In this patient group, death is likely imminent, regardless of mode,” the guidelines state.

For primary prevention, the guidelines recommend consideration of ICD implantation in patients with EF <30% and mild to moderate symptoms of HF in whom survival with good functional capacity is expected to extend beyond one year.

These ICD implants should only be considered after beta-blockers, ACE inhibitors, and angiotensin receptor blockers have failed. If patients have idiopathic cardiomyopathy and an EF of 30% to 35%, the physician may simply want to continue medical therapy rather than ICDs.

Clinicians should fully inform patients of all risks associated with ICDs before implant, including the morbidity associated with shock. Patients should also be informed that an ICD will not improve clinical function or delay progression of HF.

ACC/AHA Heart Failure guidelines Some recommendations for ICD use Use ICDs for the secondary prevention of death from ventricular tachyarrhythmia in patients with otherwise good prognosis. Use ICDs in patients with chronic HF and low EF who experience syncope of unclear origin. Consider ICDs for patients with EF <30% and mild to moderate HF symptoms and survival expected for more than one year. Consider ICDs only after beta-blockers, ACE inhibitors and angiotensin receptor blockers have failed. Fully inform all patients of risks associated with an ICD prior to implant. Some recommendations for drug use Low-dose aldosterone antagonists should be considered in carefully selected patients with moderately severe or severe HF and recent decomposition or left ventricular dysfunction early after MI. The combination of isosorbide dinitrate/hydralazine hydrochloride added to standard HF therapy may be effective in blacks with Class III or IV HF.

Drug recommendations

James Young, MD, medical director of the Kaufman Center for Heart Failure at the Cleveland Clinic Foundation, noted that the guidelines include a recommendation that low-dose aldosterone antagonists should be considered in carefully selected patients with moderately severe or severe HF symptoms and recent decomposition or left ventricular dysfunction early after MI.

“This focuses attention on another compound that when used in appropriate populations, can help reduce morbidity and mortality. The database on these drugs is not huge, but I think it’s reasonable to give them some attention,” said Young, section editor of Cardiology Today’s Myocardial Disorders, Heart Failure and Transplantation section.

The guidelines did not recommend combining aldosterone antagonists with ACE inhibitors or ARBs. In patients with chronic HF, aldosterone antagonists should be used in combination with loop diuretics.

Mann said it was also important that the guidelines recognized the importance of triple therapy: ACE inhibitors, beta-blockers, spironolactone and/or aldosterone antagonists. “This is something that most people were already doing and recommending, but it is now part of the guidelines,” he said.

The guidelines state that the combination of isosorbide dinitrate/hydralazine hydrochloride added to standard HF therapy can be effective in blacks with New York Heart Association Class III or IV HF.

The combination, in the fixed-dose formulation known as BiDil (Nitromed), was recently approved by the FDA for use in blacks.

Jay N. Cohn, MD, at the University of Minnesota and editorial board member of Cardiology Today’s Myocardial Disorders, Heart Failure and Transplantation section, said the guidelines “were not as strong as they could have been because there probably was not enough time between the results of A-HeFT and the guideline preparation to do justice to the importance of the study,” Cohn said. – by Jeremy Moore