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ACC Foundation, AHA issue guidelines for management of HF
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Investigators with the American College of Cardiology Foundation and American Heart Association highlighted several format changes that may make the recent guidelines for the management of HF easier to follow. They used the term guideline-directed medical therapy to signify the optimal medical therapy for a class I indication.
ACE inhibitors received the guideline-directed medical therapy (GDMT) designation, along with angiotensin receptor blockers for patients intolerant to ACE inhibitors. Beta-blockers, aldosterone antagonists, combined hydralazine-nitrate, and diuretics are recommended for HF with reduced ejection fraction (HFrEF).
The new guidelines offer tables and algorithms that provide practical suggestions for clinical questions. The document also aims to be in dialogue with other statements of recommendation, consensus statements and position papers, and to take into account the guidelines contained therein. The guidelines are evidence-based and feature summaries of important studies pertaining to the issue at hand.
Assessment of HF
The guidelines contain a section that compares ACCF/AHA Stages of HF with NYHA functional classification. Several multivariate risk scores are denoted as acceptable and useful measures of risk, including the CHARM risk score, the I-PRESERVE score and the Seattle Heart Failure Model.
The investigators highlighted the importance of medical history evaluation and a thorough physical examination. Clinicians are encouraged to assess for volume status and baseline characteristics measured by echocardiography. Natriuretic peptides are featured as a biomarker to be measured as an aid in guiding clinical decisions and developing prognoses for chronic ambulatory patients, patients with acute HF requiring hospitalization or selected clinically euvolemic individuals.
There is insufficient evidence to establish the utility of brain natriuretic peptide (BNP) or N-terminal prohormone of BNP (NT-proBNP) as a guide for the treatment of acutely decompensated HF, according to the researchers.
Recommended interventions
Clinicians are encouraged to educate patients and focus on transitions of care in the recommendations for non-pharmacologic interventions. Patients should understand self-care and share in the decision-making processes involved in the management of HF. The investigators suggest, for example, that patients should understand the uses and implications of an implantable cardioverter defibrillator device. The 2013 recommendations for ICDs have not changed from the previous iteration.
The guidelines also address sodium restrictions, noting that this restriction is “reasonable” as a method of reducing symptoms. The investigators note the differences in sodium restriction recommendations between the current guideline and those published by the Heart Failure Society of America in 2010 and those published by the European Society of Cardiology in 2012.
The 2013 ACCF/AHA guideline recommends exercise for eligible patients with HF.
Please see the full document for complete information on non-pharmacologic interventions.
Medical therapy recommendations
Oral pharmacologic therapies also are addressed. Aldosterone agonists are now recommended for NYHA class II patients with a history of HF requiring hospitalization or elevated plasma natriuretic peptide levels. Clinicians are encouraged to review safeguards for creatinine and monitor potassium, renal function and diuretic dosing through the follow-up period.
Combining an ACE inhibitor, angiotensin receptor blocker and aldosterone antagonist is contraindicated.
Black patients with NYHA class III to IV HFrEF or those who are intolerant to ACE inhibitors or angiotensin receptor blocker therapy may benefit from combination therapy using hydralazine and isosorbide dinitrate. Digoxin may reduce hospitalization for HF in patients with HFrEF.
Patients with left ventricular ejection fraction ≤35%, sinus rhythm, left bundle-branch block (LBBB) with a QRS duration of ≥150 ms may benefit from cardiac resynchronization therapy. Clinicians are encouraged to review the full document for complete guidelines for expanded CRT use. Guidelines for expanded use of mechanical circulatory support (MCS) also are described in detail. MCS has received a class II indication and may be considered for a variety of uses, including in patients who are candidates for cardiac transplantation.
First-line therapy for acute decompensated hospitalized HF patients remains IV loop diuretics. This therapy may be intensified or enhanced with a supplemental diuretic such as thiazide should the initial therapy prove inadequate. Low-dose dopamine infusion also may be considered as a class IIb indication in these cases. Nitroglycerine, nitroprusside or nesiritide (Natrecor, Scios) delivered intravenously also has class II indication as adjunct therapy to diuretics in patients with acutely decompensated disease without hypotension.
Please view the full document for complete information on these and other recommendations contained in the guidelines.
For more information, visit:
http://content.onlinejacc.org/article.aspx?articleid=1695826&resultClick=3#tbl9.