Updated Guidelines for Heart Failure

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have updated their guidelines on the diagnosis and management of heart failure (HF). Published jointly in the April 14, 2009 issues of Circulation and the Journal of the American College of Cardiology, the new document revised guidelines previously released in 2005. They reflect the latest research findings on the management of HF, a condition that affects approximately 5.7 million Americans. “The purpose of the guideline update is to provide clinicians with recommendations for care using the best-available evidence,” says Mariell Jessup, MD, FACC, FAHA, who chaired the ACCF/AHA writing committee that updated the guidelines. “The new recommendations are based on randomized clinical trials and important registry data whenever possible.”

Key Revisions

Among several key updates, the new guidelines incorporate recommendations about the management of acute HF in the hospitalized patient. In addition, the document includes concrete recommendations on the use of a fixed-dose combination of hydralazine and isosorbide dinitrate. The recommendation concerning hydralazine and isosorbide dinitrate was strengthened based on findings from the A-HeFT (African-American Heart Failure Trial) trial. “The complete evidence resulting from A-HeFT was not available at the time of the publication of the last guidelines in 2005,” says Dr. Jessup. “We therefore felt it was important to strengthen the recommendation to Class I so that all self-identified African Americans who remained symptomatic despite optimal medical therapy would be offered the hydralazine/isosorbide dinitrate combination.”

In order to keep recommendations in alignment with those from the ventricular arrhythmia guidelines published by the ACCF/AHA, the document also clarifies previous recommendations surrounding the use of implantable cardioverter defibrillators (ICDs) and/or cardiac resynchronization therapy as primary prevention. The previous Class 1 recommendation was for patients with a left ventricular ejection fraction (LVEF) of 30% or less. However, a significant group of patients have LVEFs between 30% and 35%; ICDs were separately recommended for this LVEF range, but it was based on weaker evidence. The current document brings the threshold to 35% or less. “We also reviewed the available evidence about guiding HF therapy using natriuretic peptide assessment,” Dr. Jessup says. “We concluded that there isn’t enough evidence to suggest that these natriuretic peptide assessments should be used routinely in the management of HF patients.”

Hospitalized Patients

The revised ACCF/AHA guidelines include a new section on hospitalized patients regarding diagnosis, treatment, and discharge (Table). The writing committee felt strongly that the management of hospitalized patients with HF needed to be included in the guideline update, explains Dr. Jessup. “Heart failure is currently the top reason why patients older than 65 are hospitalized, accounting for more than 1.1 million hospitalizations annually. Moreover, readmission following a HF hospitalization is common, and the 30-day mortality rate is extremely high.”

Registry data suggest that most patients hospitalized with HF only received diuretic therapy as an intervention. “Also, only about half of these patients ever get their LVEF documented,” Dr. Jessup adds. “Patients are often sent home from the hospital without evidence-based therapy. The registry data concluded that there is inconsistency of care and inappropriate care to this important patient population.”

Patient Education

Patients hospitalized for HF as well as their caregivers are recommended to receive comprehensive written discharge instructions that emphasize diet, discharge medications, activity level, follow-up appointments, daily weight monitoring, and what to do if HF symptoms worsen. “Education is critical in helping keep patients out of the hospital following their index hospitalization,” says Dr. Jessup. “Educating patients about dietary measures (eg, salt restriction) and fluid restriction and explaining the role of medications, expected side effects, and the need for continuation of therapy are important components of the educational process for patients.”

Another measure that has been increasingly emphasized is to develop action plans with patients, Dr. Jessup says. “These plans should be created in case patients develop new signs of fluid retention or symptoms of breathlessness. Clinicians must articulate these plans clearly whenever patients are being discharged. Helping patients know what to do for each symptom, when to call their doctor, and when to seek immediate medical attention can help reduce the burden of HF on healthcare systems.”

The intent of the revised ACCF/AHA guidelines is to help clinicians with more clarified recommendations. “We’ve identified areas in HF where there are good data to provide recommendations,” says Dr. Jessup. “However, there are still some gaps in our knowledge that must be addressed. We’ll continue to work towards revising these guidelines in a timely fashion and to ensure that they’re easily accessible to help busy clinicians caring for this important patient group.”