Managing Heart Failure: A Focused Update

Guideline Watch |
July 12, 2017

Managing Heart Failure: A Focused Update

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

The update addresses treatment changes for patients with either preserved or reduced systolic function.

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

Sponsoring Organizations: American College of Cardiology (ACC) Foundation, American Heart Association (AHA), and the Heart Failure Society of America in collaboration with American Academy of Family Physicians, American College of Chest Physicians, and International Society for Heart and Lung Transplantation

Target Audience: Cardiovascular specialists, cardiac surgeons, and primary care clinicians providing care to patients with heart failure (HF).

Background and Objective

This update of the 2013 ACC/AHA guideline is based on a review of clinical trials that were presented at national and international scientific meetings and published in the peer-reviewed literature between April 2013 and November 2016.

Key Points

1. Biomarkers: Natriuretic peptides are useful for diagnosis in patients with suspected HF or for prognosis (Class I [strong recommendations]) and might help to identify patients at risk for HF who might benefit from team-based preventive care (Class IIa [moderate recommendation]). Troponin levels at the time of hospitalization are also useful for prognostication (Class I). The value of using biomarkers in guiding therapy is not clear.

2. Renin-Angiotensin System Inhibition: This strategy is recommended to reduce morbidity and mortality in all patients with HF and reduced ejection fraction (HFrEF) and no contraindications, in addition to optimal therapy that includes beta blockers and aldosterone antagonists in those without contraindications as well as device therapy (implantable cardioverter-defibrillator cardiac resynchronization therapy, or both) in those with an indication.

  • Angiotensin-converting enzyme (ACE) inhibitors (Class I) or

  • Angiotensin receptor blockers (ARBs, Class I) or

  • Angiotensin receptor–neprilysin inhibitor (ARNI) to replace ACE inhibitors or ARBs in patients who have tolerated either agent (Class I, but with a lower level of evidence than ACE or ARB). ARNI should not be used within 36 hours of the last dose of an ACE inhibitor or in patients with angioedema (Class III [harm]).

3. Ivabradine: Consider using this drug to reduce HF hospitalizations for symptomatic HFrEF and resting heart rate ≥70 bpm in patients on optimal therapy, including a beta blocker at the maximal tolerated dose (Class IIa).

4. Therapy for HF with Preserved Ejection Fraction (HFpEF): Therapy remains largely targeted at coexisting conditions, including hypertension, coronary disease, and atrial fibrillation. ARBs in appropriately selected patients might reduce hospitalization risk (Class IIb [weak recommendation]). Routine nitrates or phosphodiesterase-5 inhibitors are discouraged (Class III [no benefit]).

5. Anemia and Iron Deficiency: Intravenous iron to improve health status is recommended for symptomatic patients with HF and iron deficiency (Class IIb). Erythropoietin-stimulating agents should not be used (Class III [no benefit]).

6. Hypertension: Recommended optimal levels (Class I) are <130/80 mm Hg for those at risk for HF (stage A) or systolic <130 mm Hg in patients with HFrEF or HFpEF.

7. Sleep-Disordered Breathing: Screening (Class IIa) and treatment of obstructive sleep apnea (Class IIb) to reduce sleepiness are recommended. Adaptive servo-ventilation in patients with central sleep apnea should be avoided (Class III [harm]).

What's Changed

This update includes new recommendations on substituting ARNI for ACE or ARB in HFrEF and selective use of ivabradine in optimally managed patients with HFrEF, plus a modest recommendation for aldosterone antagonists for HFpEF. The dos and don'ts for treating coexisting conditions integrate data from other randomized trials.

Comment

Many clinicians might be uncomfortable using ARNI for HFrEF because of concerns about adverse effects; this document provides helpful guidance. HFpEF treatment remains frustrating because of the lack of definitive positive trials. The recommendations for treating coexisting conditions remind us of the complexity of caring for patients with HF. The best care considers issues well beyond the heart.

Dr. Masoudi was a member of the writing committee for this guideline update.

Editor Disclosures at Time of Publication

  • Disclosures for Frederick A. Masoudi, MD, MSPH, FACC, FAHA at time of publication Grant / Research support National Heart, Lung, and Blood Institute; American College of Cardiology; Patient-Centered Outcomes Research Institute; John. A. Hartford Foundation Editorial boards UpToDate Leadership positions in professional societies American College of Cardiology (Chief Science Officer, National Cardiovascular Data Registries; Member, Board of Trustees); American Heart Association (Immediate Past Chair, Council on Quality of Care and Outcomes Research); American Board of Internal Medicine (Member, Cardiology Board)

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