Heart failure guideline summary

Heart Failure Guidelines

The 2009 revision of the ACC/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults contains a number of evidence-based updates, revised text, and a new section called "hospitalized patient" (Hunt et al. e395). These revisions are the result of a task force that convened in 2008 and represent new findings published between 2005 and 2008.

Four stages along a continuum of heart failure are described, with the first two stages representing patients having medical conditions that increase the risk of heart failure (Hunt et al. e396). Stage A patients may have atherosclerosis, diabetes, hypertension, obesity, metabolic syndrome, or have a family history of heart failure, but without structural heart disease (Hunt et al. e405-e408). Treatment strategies for Stage A patients include aggressive management of medical conditions and encouraging lifestyle changes. Stage A patients with vascular disease or diabetes may also benefit from ACE inhibitors or ARBs.

Stage B. patients have structural heart disease, but do not have heart failure (Hunt et al. e408-e410). Asymptomatic valvular disease, left ventricular remodeling, or a history of myocardial infarctions qualify patients for Stage B. classification. Treatment goals are the same as for State A patients, but may also involve the use of beta-blockers and implantable cardioverter-defibrillators (ICDs).

Stage C. And D. patients have heart failure, but most heart failure patients will be Stage C (Hunt et al. e410-e431). Accordingly, the revised guidelines spend the most time addressing evaluation and treatment strategies for Stage C. patients. These patients have structural heart disease, shortness of breath, fatigue, and reduced exercise tolerance. In addition to the treatment strategies suggested for Stage A and B. patients, Stage C. patients may be put on a low-sodium diet and routinely use ACE inhibitors, beta-blockers, and diuretics for fluid retention. Some patients may require aldosterone antagonists, ARBs, digitalis, hydralazine/nitrates, biventricular pacing, and/or ICDs.

Stage D. patients have refractory heart failure at rest (Hunt et al. e432-440). These patients typically experience frequent hospitalizations or may be indefinitely hospitalized. Treatment goals are the same for Stage A, B, and C. patients, but may include consideration of end-of-life care options. These patients may also take part in experimental procedures and drug trials, including heart transplant or permanent mechanical support.

Updates

Since the bulk of the revised guidelines are concerned with Stage C. patients, this section on the 2009 updates are naturally concerned with evaluating and treating Stage C. patients. The following are some of the more important updates:

1. Patients who present in an urgent care setting with possible heart failure can be evaluated in part by measuring natriuretic peptides. The 2005 guidelines recommended brain natriuretic peptide (BNP), but the revised guidelines suggest the inclusion of NT-proBNP (N-terminal prohormone brain natriuretic peptide) (Hunt et al. e399).

2. Patients with reduced left ventricular ejection fraction (LVEF) who have intolerance to ACE inhibitors should use ARBs (Hunt et al. e410). When these patients are being evaluated for an exercise program, maximal testing, with or without respiratory gas exchange measurements, is no longer required, but optional (Hunt et al. e411).

3. ICDs are recommended in patients with non-ischemic dilated cardiomyopathy, ischemic heart disease patients who have 40 days of recovery since the last myocardial infarction, patients with an LVEF of 35% or less, and New York Heart Association (NYHA) functional class II or III symptom patients with survival chances greater than a year (Hunt et al. e411).

4. ICDs have not proven beneficial for patients with less than a year of recovery from the last acute coronary event (Hunt et al. e410-e412). ICDs should be considered for LVEF patients only after medication therapy with beta-blockers and ACE inhibitors, or ARBs, have failed to improve symptoms. ICDs are not recommended for Stage D. patients or for patients with a short life expectancy due to comorbid conditions.

5. Unless contraindicated, patients with cardiac dyssynchrony who continue to have 35% or less LVEF, NYHA functional class III or ambulatory class IV symptoms, and sinus rhythm after receiving recommended medical interventions, should be given cardiac resynchronization therapy (RCT) (Hunt et al. e411). RCT has proven beneficial for symptom reduction, improved LVEF, increased exercise tolerance, quality of life, and survival.

6. Patients with Stage D. heart failure should not receive intermittent infusions of positive inotropic or vasoactive agents (Hunt et al. e412).