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2013 Heart Failure Guidelines

January 28, 2014

2013 Heart Failure Guidelines

  1. Frederick A. Masoudi, MD, MSPH, FACC, FAHA

A comprehensive revision reflects a growing evidence base.

  1. Frederick A. Masoudi, MD, MSPH, FACC, FAHA

Sponsoring Organizations: American College of Cardiology (ACC) Foundation, American Heart Association (AHA), American College of Chest Physicians, Heart Rhythm Society, International Society for Heart and Lung Transplantation

Target Population: Primary care providers and specialists caring for patients with heart failure (HF).

Background and Objective

This document is a thorough revision of the 2005 ACC/AHA HF guidelines (updated in early 2009). The writers reviewed studies published through October 2011 (with selected additional data published before April 2013).

Key Recommendations

Class I recommendations for initial evaluation include:

  • History and physical examination

  • Family history in patients with dilated cardiomyopathy

  • Weight and volume status

  • Complete blood count, urinalysis, electrolytes, lipids, liver panel, and thyroid-stimulating hormone

  • Electrocardiogram

  • Chest radiograph

  • 2-dimensional echocardiogram with assessment of left ventricular (LV) systolic function.

Class I recommendations for the use of B-type natriuretic peptide (BNP) or N-terminal pro-BNP include:

  • Assessing the likelihood of HF in ambulatory patients with dyspnea or patients with possible acute decompensated HF when the diagnosis is uncertain

  • Establishing prognosis or disease severity

Patients with asymptomatic LV systolic dysfunction (LVSD) should receive an angiotensin-converting enzyme (ACE) inhibitor and a β-blocker to prevent symptomatic HF (Class I).

In the absence of contraindications, patients with symptomatic LVSD should receive guideline-directed medical therapy (GDMT) consisting of ACE inhibitor (or angiotensin-receptor blocker), β-blocker, and:

  • Loop diuretics, if needed for volume overload

  • Aldosterone antagonists in patients with symptoms of any severity or following acute myocardial infarction (MI), provided that estimated glomerular filtration rate is >30 mL/min/1.73m2 and potassium levels are <5 mEq/dL.

  • Hydralazine and nitrate combination in black patients with severe symptoms despite other therapy (all Class I).

Only those β-blockers proven to improve HF outcomes — long-acting metoprolol, carvedilol, or bisoprolol — should be used in patients with LVSD (Class I).

In the absence of contraindications, patients with HF and atrial fibrillation (AF) with an additional risk factor for stroke should receive systemic anticoagulation with warfarin or other approved agents (Class I). The value of anticoagulation in other circumstances is less clear.

Agents that are not beneficial or harmful for LVSD include statins (solely for HF), nutritional supplements, hormonal therapies, calcium channel blockers, nonsteroidal anti-inflammatory drugs, thiazolidinediolnes, and long-term infused inotropic drugs (all Class III).

Evidence-based approaches to HF patients with preserved systolic function are lacking; recommendations for this group are generic and target coexisting conditions (e.g., hypertension and AF).

Recommendations for implantable cardioverter-defibrillator therapy (in many patients with LV ejection fractions <35%) and cardiac resynchronization therapy (CRT; in those with LVSD and QRS prolongation) are consistent with current device-based therapy guidelines (NEJM JW Cardiol Oct 3 2012) and include expanding CRT consideration to patients with New York Heart Association class II symptoms (Class I).

Transplantation should be considered in patients with stage D HF that is refractory to GDMT, device, and surgical therapies (Class I).

Transitional care at hospital discharge, palliative care, care coordination (all Class I), and participation in quality-improvement initiatives (Class IIa) are encouraged.

What's Changed

These guidelines provide a concrete definition of GDMT. The recommendations for both aldosterone antagonists and CRT are expanded to patients with milder symptoms. A substantially greater emphasis is placed on care transitions, patient engagement, and quality improvement, all of which are important but can be difficult to achieve. Several approaches that are either not beneficial or harmful are highlighted, providing useful targets for improving the quality and efficiency of HF care.

Comment

Although none of the changes in this guideline are seismic, the update is welcome, given the substantial body of evidence generated since its last iteration. Most of the recommendations in this document require functional systems of care in both the inpatient and outpatient settings and cannot be achieved by an individual practitioner in isolation.

Dr. Masoudi was a member of the writing committee for these guidelines.

  • Disclosures for Frederick A. Masoudi, MD, MSPH, FACC, FAHA at time of publication Royalties Darling, Milligan, Smith & Lesch Grant / research support Agency for Healthcare Research and Quality; American College of Cardiology; Patient-Centered Outcomes Research Institute Editorial boards Circulation: Cardiovascular Quality and Outcomes Leadership positions in professional societies American College of Cardiology (Senior Medical Officer, National Cardiovascular Data Registries); American Heart Association (Vice Chair, Council on Quality of Care and Outcomes Research)

Citation(s):

Reader Comments (12)

Manohar Physician, Nephrology

In assessment labs only electrolytes have been advised, how would one know GFR if Renal function panel is not included. And it's good that Urinalysis &/or LFTs was added in lab work for A/P, but no comments about it's use in decision making!

amina arshad Physician, Internal Medicine

what about the use of statin in patient with HF and known CAD?

Nicola Carfagnini Physician, Neurology, Larino, italy

What the attuale role for BNP (brain natruretic peptide) in management of HF?

Juarez Barbisan Physician, Cardiology, Instituto de Cardiologia RS/Brasil

The management of atrial fibrilation is lacking.

Favio Rojas Physician, Cardiology, Figueras

There is no comment about digoxin. What will be his role?

Favio Rojas Physician, Cardiology, Figueras

There is no comment about digoxin. What will be his role?

KALLINIKOS TSAKONAS Physician, Cardiology

LV HEART FAILURE IS '' WELL''' KNOWN IN CLINICAL PRACTICE BUT WHAT ABOUT RV - HEART FAILURE AND P.A.H THAT IS A CONFUSED CLINICAL PROBLEM IN PRACTICING CLINICAL CARDIOLOGY PRIVETELY . ..

Humberto Olivencia Rabell Physician, Hospital Perea

Clear, simple and progressive guidelines, based on accumulated experience and evidence based medicine

JAIRO UMANA Physician, Internal Medicine, universidad tecnologica pereira

The message is confused about statin

Orlando López Physician, Family Medicine/General Practice

Excelentes datos. claros, útiles. Felicitaciones.

ANTONIO COSTA Physician, Family Medicine/General Practice, Medical Clinic

Very useful guidelines

IBRAHEEM LASHEEN Physician, Hospital Medicine, Kuwait

Clear guidelines

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