Diet for heart failure patients
Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of intravenous diuretics or active titration of HF medications. Therefore, the clinician must, as always, practice the art of using the best of the guideline recommendations as they apply to a specific patient. Goetze JP, Mogelvang R, Maage L, et al. As a result, in response to pilot projects, several changes to these guidelines will be apparent, including limited narrative text, a focus on summary and evidence tables (with references linked to abstracts in PubMed), and more liberal use of summary recommendation tables (with references that support LOE) to serve as a quick reference. Drazner MH, Hellkamp AS, Leier CV, et al. Reviewer Relationships With Industry and Other Entities (Relevant) 1849. Chronic heart failure: management of chronic heart failure in adults in primary and secondary care (NICE clinical guideline 108): Available at:. When ischemia may be contributing to HF, coronary arteriography is reasonable for patients eligible for revascularization. Coordinating Care for Patients With Chronic HF: Recommendations. The recommendations in this guideline are considered current until they are superseded by a focused update or the full-text guideline is revised. The committee was composed of physicians and a nurse with broad expertise in the evaluation, care, and management of patients with heart failure (HF). Experts in the subject under consideration are selected by the ACCF and AHA to examine subject-specific data and write guidelines in partnership with representatives from other medical organizations and specialty groups. The ultimate judgment regarding care of a particular patient must be made by the clinician and patient in light of all the circumstances presented by that patient. See Table 16 for a summary of recommendations from this section. See Table 17 for a summary of recommendations from this section. 306. Diuretics are recommended in patients with HF r EF who have evidence of fluid retention, unless contraindicated, to improve symptoms. Usefulness of intermediate amino-terminal pro-brain natriuretic peptide concentrations for diagnosis and prognosis of acute heart failure. Dr Henry Black speaks with cardiologist Paul Thompson on how the best exercise practices are often the simplest. The schema for COR and LOE are summarized in Table 1, which also provides suggested phrases for writing recommendations within each COR. Guidelines are official policy of both the ACCF and AHA. Jourdain P, Jondeau G, Funck F, et al. Bedside cardiovascular examination in patients with severe chronic heart failure: importance of rest or inducible jugular venous distension. Selected Multivariable Risk Scores to Predict Outcome in HF. Okonko DO, Mandal AK, Missouris CG, et al. Footnotes Developed in Collaboration With the American College of Chest Physicians, Heart Rhythm Society, and International Society for Heart and Lung Transplantation Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation WRITING COMMITTEE MEMBERS Full-text guideline available at:. Dr Sam Goldhaber makes a case for reconsidering the use of inferior vena cava filters in certain scenarios. Routine use of nutritional supplements is not recommended for patients with HF p EF. See Table 14 for a summary of recommendations from this section and Table 15 for strategies for achieving optimal GDMT. Predictors of mortality after discharge in patients hospitalized with heart failure: an analysis from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF). Screening for hemochromatosis or HIV is reasonable in selected patients who present with HF. Beta-blocker therapy should be initiated at a low dose and only in stable patients. John J. Berger R, Huelsman M, Strecker K, et al. Mariell Jessup Find this author on Google Scholar. Davis M, Espiner E, Richards G, et al. The recommendations listed in this document are, whenever possible, evidence based. When diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either. See Table 13 for a summary of the treatment benefit of GDMT in HF r EF. Members are not permitted to draft or vote on any text or recommendations pertaining to their RWI. Porapakkham P, Porapakkham P, Zimmet H, et al. This document was approved by the American College of Cardiology Foundation Board of Trustees and the American Heart Association Science Advisory and Coordinating Committee in May 2013. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. 127 (Level of Evidence: B). Frailty May Raise Post-TAVR Risk of Delirium, Death. V. (Level of Evidence: C). Searches were extended to studies, reviews, and other evidence conducted in human subjects and that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected databases relevant to this guideline. Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea. Komajda M, Carson PE, Hetzel S, et al. Survival From Congenital Heart Disease Climbs, but Risks Remain. Cardiac troponin I is associated with impaired hemodynamics, progressive left ventricular dysfunction, and increased mortality rates in advanced heart failure. Classification of patients presenting with acutely decompensated heart failure. Intravenous Inotropic Agents Used in Management of HF. See Table 22 for a summary of recommendations from this section and Figure 4 for the classification of patients presenting with acutely decompensated HF. 248 (Level of Evidence: B). Factors associated with outcome in heart failure with preserved ejection fraction: findings from the Irbesartan in Heart Failure with Preserved Ejection Fraction Study (I-PRESERVE). What is critically needed is an evidence base that clearly identifies best processes of care, especially in the transition from hospital to home. Predictors of mortality and morbidity in patients with chronic heart failure. Patients with HF admitted with evidence of significant fluid overload should be promptly treated with intravenous loop diuretics to reduce morbidity. Rose Marie Robertson, MD, FAHA, Chief Science Officer. Guyatt GH, Akl EA, Crowther M, et al. Chobanian AV, Bakris GL, Black HR, et al. HF is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood. Pocock SJ, Wang D, Pfeffer MA, et al. The present document recommends a combination of lifestyle modifications and medications that constitute GDMT. Information should be provided about the efficacy, safety, and potential complications of an ICD and the potential for defibrillation to be inactivated if desired in the future, notably when a patient is approaching end of life. Disparities in the epidemiology of HF have been identified. 305 (Level of Evidence: C). Moreover, clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools. The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. Recommendations for Pharmacological Therapy for Management of Stage C HFrEF. See Table 10 for oral diuretics recommended for use in the treatment of chronic HF. Maisel AS, Krishnaswamy P, Nowak RM, et al. Predictors of fatal and non-fatal outcomes in the Controlled Rosuvastatin Multinational Trial in Heart Failure (CORONA): incremental value of apolipoprotein A-1, high-sensitivity C-reactive peptide and N-terminal pro B-type natriuretic peptide. Recommendations for the use of mechanical circulatory support: device strategies and patient selection: a scientific statement from the American Heart Association. Usefulness of plasma galectin-3 levels in systolic heart failure to predict renal insufficiency and survival. (Level of Evidence: C). Javed Butler Find this author on Google Scholar. Clinical significance of elevated levels of cardiac troponin T in patients with chronic heart failure. (Level of Evidence: C). Writing committee members volunteered their time for this activity. (Level of Evidence: C). (Level of Evidence: C). Felker GM, Hasselblad V, Hernandez AF, et al. Analyze This Image: Young and Short of Breath. Admission, discharge, or change in B-type natriuretic peptide and long-term outcomes: data from Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) linked to Medicare claims. Some patients have exercise intolerance but little evidence of fluid retention, whereas others complain primarily of edema, dyspnea, or fatigue. Fonarow GC, Adams KF Jr. However, this guideline does address HF with preserved ejection fraction (EF) in more detail and similarly revisits hospitalized HF. This article has been copublished in the Journal of the American College of Cardiology. See Table 18 for the European Society of Cardiology definition of advanced HF and Table 19 for clinical events and findings useful for identifying patients with advanced HF. Amino-terminal pro-B-type natriuretic peptide and B-type natriuretic peptide in the general community: determinants and detection of left ventricular dysfunction. (Level of Evidence: C) 3. ICD therapy is recommended for primary prevention of sudden cardiac death to reduce total mortality in selected patients with nonischemic dilated cardiomyopathy or ischemic heart disease at least 40 days post-MI with LVEF of 35% or less and NYHA class II or III symptoms on chronic GDMT, who have reasonable expectation of. Patel MR, Dehmer GJ, Hirshfeld JW, et al. Triage after hospitalization with advanced heart failure: the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) risk model and discharge score. Ultrafiltration may be considered for patients with obvious volume overload to alleviate congestive symptoms and fluid weight. Treatment of Stages A to D: Recommendations 1820. Drs Harrington and Weiss discuss the controversial SPRINT trial and why some think its methods are not doable in clinical practice. Disordered iron homeostasis in chronic heart failure: prevalence, predictors, and relation to anemia, exercise capacity, and survival. Genetics and cardiovascular disease: a policy statement from the American Heart Association. See Table 12 for aldosterone receptor antagonists drug dosing. Even the widely embraced dictum of sodium restriction in HF is not well supported by current evidence. Peura JL, Colvin-Adams M, Francis GS, et al. Sarah Jackson, MPH, Specialist, Science and Clinical Policy. Use of amino-terminal pro-B-type natriuretic peptide to guide outpatient therapy of patients with chronic left ventricular systolic dysfunction. Aaronson KD, Schwartz JS, Chen TM, et al. Prescribed courses of treatment in accordance with these recommendations are effective only if followed. Coordinating Care for Patients With Chronic HF: Recommendations 1835 11. Troughton RW, Frampton CM, Yandle TG, et al. Nondihydropyridine calcium channel blockers with negative inotropic effects may be harmful in asymptomatic patients with low LVEF and no symptoms of HF after MI. 334, 343, 382 (Level of Evidence: B). Plasma N-terminal pro-brain natriuretic peptide and adrenomedullin: prognostic utility and prediction of benefit from carvedilol in chronic ischemic left ventricular dysfunction: Australia-New Zealand Heart Failure Group. Biomarker-guided therapy in chronic heart failure: a meta-analysis of randomized controlled trials. The clinical syndrome of HF may result from disorders of the pericardium, myocardium, endocardium, heart valves, or great vessels, or from certain metabolic abnormalities, but most patients with HF have symptoms due to impaired left ventricular (LV) myocardial function. Ezaldeen Ramadhan III, Specialist, Science and Clinical Policy. Neuhold S, Huelsmann M, Strunk G, et al. It is also of major concern that the majority of randomized controlled trials failed to randomize a sufficient number of the elderly, women, and underrepresented minorities, thus limiting our insight into these important patient cohorts. Evaluation for cardiac transplantation is indicated for carefully selected patients with stage D HF despite GDMT, device, and surgical management. Smith SC Jr. Usefulness of B-type natriuretic peptide levels in predicting hemodynamic and clinical decompensation. Stages in the development of HF and recommended therapy by stage. Author Relationships With Industry and Other Entities (Relevant) 1846 Appendix 2. 63 (Level of Evidence: C) Diagnostic tests for rheumatologic diseases, amyloidosis, or pheochromocytoma are reasonable in patients presenting with HF in whom there is a clinical suspicion of these diseases. Moreover, the majority of the clinical trials that inform GDMT were designed around the primary endpoint of mortality, so that there is less certainty about the impact of therapies on the health-related quality of life of patients. Characteristics, treatments, and outcomes of patients with preserved systolic function hospitalized for heart failure: a report from the OPTIMIZE-HF Registry. Furie KL, Goldstein LB, Albers GW, et al. 176,196 (Level of Evidence: A). National Collaborating Centre for Acute and Chronic Conditions. Work dissatisfaction has pushed many physicians into early retirement. A thorough review of these reports and of our current methodology is under way, with further enhancements anticipated. Invasive hemodynamic monitoring with a pulmonary artery catheter should be performed to guide therapy in patients who have respiratory distress or clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment. Recommendations for Inotropic Support, MCS, and Cardiac Transplantation. Writing committees are charged with regularly reviewing and evaluating all available evidence to develop balanced, patient-centric recommendations for clinical practice. Dao Q, Krishnaswamy P, Kazanegra R, et al. The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the members of the writing committee. 28,247 (Level of Evidence: B) Diuretics should be used for relief of symptoms due to volume overload in patients with HF p EF. Development and prospective validation of a clinical index to predict survival in ambulatory patients referred for cardiac transplant evaluation. Stage C HF r EF: evidence-based, guideline-directed medical therapy. Sato Y, Yamada T, Taniguchi R, et al. (Level of Evidence: C). Anand IS, Fisher LD, Chiang YT, et al. Differences in the incidence of congestive heart failure by ethnicity: the Multi-Ethnic Study of Atherosclerosis. Initial and Serial Evaluation of the HF Patient: Recommendations 6. Dr Pina interviews Dr Packer about his trial on ularitide infusion in patients with acute decompensated heart failure, which was presented at the American Heart Association meeting. Jody Hundley, Production Manager, Scientific Publications, Office of Science Operations. W. The relevant data are included in evidence tables in the Data Supplement. Accessed March 11, 2013. The reader is referred to publically available resources to address questions in these areas. Routine repeat measurement of LV function assessment in the absence of clinical status change or treatment interventions should not be performed. Judy Bezanson, DSN, RN, CNS-MS, FAHA, Science and Medicine Advisor. See Table 7 for a summary of recommendations from this section. Comprehensive disclosure information for the Task Force is also available online at. , Rehman SU, Mohammed AA, et al. The Seattle Heart Failure Model: prediction of survival in heart failure. Utility of B-type natriuretic peptide in the diagnosis of congestive heart failure in an urgent-care setting. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. Appendix 2. , Benjamin EJ, Bonow RO, et al. The use of ARBs might be considered to decrease hospitalizations for patients with HF p EF. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations. Lifetime risk for developing congestive heart failure: the Framingham Heart Study. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment and be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, for which the benefit-to-risk ratio may be lower. High levels of plasma brain natriuretic peptide and interleukin-6 after optimized treatment for heart failure are independent risk factors for morbidity and mortality in patients with congestive heart failure. Although there is an abundance of evidence addressing HF, for many important clinical considerations, this writing committee was unable to identify sufficient data to properly inform a recommendation. Decision making in advanced heart failure: a scientific statement from the American Heart Association. Clinical decision making should involve consideration of the quality and availability of expertise in the area where care is provided. Recommendations for Device Therapy for Management of Stage C HF. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. All writing committee members and peer reviewers of the guideline are required to disclose all current healthcare-related relationships, including those existing 12 months before initiation of the writing effort. Medical Therapy for Stage C HFrEF: Magnitude of Benefit Demonstrated in RCTs. Drazner MH, Rame JE, Stevenson LW, et al.
As other techniques may indicate abnormalities in systolic function among patients with a preserved EF, it is preferable to use the terms preserved or reduced EF over preserved or reduced systolic function. As a result, situations may arise for which deviations from these guidelines may be appropriate. Levy WC, Mozaffarian D, Linker DT, et al. Adherence to the clinical practice guidelines herein reproduced should lead to improved patient outcomes. N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute heart failure: primary results of the Canadian prospective randomized multicenter IMPROVE-CHF study. (Level of Evidence: C). Smartphone-App Population Study Hints at Future of CV Research. 3. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another have been added for COR I and IIa, LOE A or B only. The work of writing committees is supported exclusively by the ACCF and AHA without commercial support. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. Wilson Tang Find this author on Google Scholar. Kociol RD, Horton JR, Fonarow GC, et al. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. Comparison of copeptin, B-type natriuretic peptide, and amino-terminal pro-B-type natriuretic peptide in patients with chronic heart failure: prediction of death at different stages of the disease. Invasive hemodynamic monitoring can be useful for carefully selected patients with acute HF who have persistent symptoms despite empiric adjustment of standard therapies and. Setsuta K, Seino Y, Takahashi N, et al. Endomyocardial biopsy can be useful in patients presenting with HF when a specific diagnosis is suspected that would influence therapy. OpenUrl CrossRef Medline 96. A combination of hydralazine and isosorbide dinitrate can be useful to reduce morbidity or mortality in patients with current or prior symptomatic HF r EF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency, unless contraindicated. Lindenfeld J, Albert NM, Boehmer JP, et al. Oetgen, MD, MBA, FACC, Senior Vice President, Science and Quality. 148 (Level of Evidence: B). Peterson PN, Rumsfeld JS, Liang L, et al. If you log out, you will be required to enter your username and password the next time you visit. B-type natriuretic peptide-guided heart failure therapy: a meta-analysis. Treatment of Stages A to D: Recommendations 7. See Table 9 for a summary of recommendations from this section. McMurray Find this author on Google Scholar. Mueller C, Scholer A, Laule-Kilian K, et al. N-terminal pro-B-type natriuretic peptide-guided treatment for chronic heart failure: results from the BATTLESCARRED (NT-proBNP-Assisted Treatment To Lessen Serial Cardiac Readmissions and Death) trial. Recommendations for Therapies in the Hospitalized HF Patient. Patient-specific modifiers, comorbidities, and issues of patient preference that may influence the choice of tests or therapies are considered. McMurray JJ, Adamopoulos S, Anker SD, et al. Finally, preventing the burden of this disease through more successful risk modification, sophisticated screening, perhaps using specific omics technologies (ie, systems biology), or effective treatment interventions that reduce the progression from stage A to stage B is an urgent need. Plasma pro-B-type natriuretic peptide in the general population: screening for left ventricular hypertrophy and systolic dysfunction. Healthy Lifestyle Can Partly Counter Genetic Coronary Risk. Costello-Boerrigter LC, Boerrigter G, Redfield MM, et al. All guideline recommendations require a confidential vote by the writing committee and must be approved by a consensus of the voting members. Additional areas of renewed interest are stage D HF, palliative care, transition of care, and quality of care for HF. H. Maron BJ, Towbin JA, Thiene G, et al. Members who recused themselves from voting are indicated in the list of writing committee members, and specific section recusals are noted in Appendix 1. 319 (Level of Evidence: B) Ultrafiltration may be considered for patients with refractory congestion not responding to medical therapy. 231,232 (Level of Evidence: B) Hormonal therapies other than to correct deficiencies are not recommended for patients with current or prior symptoms of HF r EF. 310,311 (Level of Evidence: B) If patients are already receiving loop diuretic therapy, the initial intravenous dose should equal or exceed their chronic oral daily dose and should be given as either intermittent boluses or continuous infusion. References selected and published in this document are representative and not all-inclusive. Persistently increased serum concentrations of cardiac troponin t in patients with idiopathic dilated cardiomyopathy are predictive of adverse outcomes. The writing committee reviews and ranks evidence supporting each recommendation with the weight of evidence ranked as LOE A, B, or C according to specific definitions that are included in Table 1. See Table 6 for a summary of recommendations from this section. Balady GJ, Ades PA, Bittner VA, et al. Survey: Most Want Some Parts of ACA to Stay. , Abraham WT, et al. Relationship between B-type natriuretic peptides and pulmonary capillary wedge pressure in the intensive care unit. The committee included representatives from the ACCF, AHA, American Academy of Family Physicians, American College of Chest Physicians, American College of Physicians, Heart Rhythm Society, and International Society for Heart and Lung Transplantation. Thygesen K, Alpert JS, Jaffe AS, et al. Horwich TB, Patel J, MacLellan WR, et al. Please confirm that you would like to log out of Medscape. Plasma brain natriuretic peptide-guided therapy to improve outcome in heart failure: the STARS-BNP Multicenter Study. The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly produced guidelines in the area of cardiovascular disease since 1980. Coordinating Care for Patients With Chronic HF: Recommendations Appendix 1. Prognostic value of galectin-3, a novel marker of fibrosis, in patients with chronic heart failure: data from the DEAL-HF study. 188 (Level of Evidence: B). B-type natriuretic peptide predicts sudden death in patients with chronic heart failure. Vasan RS, Benjamin EJ, Larson MG, et al. Despite the objective evidence compiled by the writing committee on the basis of hundreds of clinical trials, there are huge gaps in our knowledge base about many fundamental aspects of HF care. EF values are dependent on the imaging technique used, method of analysis, and operator. Januzzi JL Jr. Lisa Bradfield, CAE, Director, Science and Clinical Policy. The reader is encouraged to consult the full-text guideline 4 for additional guidance and details about heart failure, because the Executive Summary contains only the recommendations. Ashley EA, Hershberger RE, Caleshu C, et al. Untreated stroke rates in AF, beta-blocker use in the frail elderly, healthy lifestyle, and meeting unmet needs in disadvantaged patients are discussed this week by Dr John Mandrola. (Level of Evidence: C). Nutritional supplements as treatment for HF are not recommended in patients with current or prior symptoms of HF r EF. Stage C HF r EF: evidence-based, guideline-directed medical therapy. (Level of Evidence: C). Patients with NYHA class II HF should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide levels to be considered for aldosterone receptor antagonists. This guideline covers multiple management issues for the adult patient with HF. Lee DS, Austin PC, Rouleau JL, et al. See Table 5 for multivariable clinical risk scores. An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist clinicians in selecting the best management strategy for an individual patient. Johnson International Society for Heart and Lung Transplantation representative. Warnes CA, Williams RG, Bashore TM, et al. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For the remainder of this guideline, we will consistently refer to HF with preserved EF and HF with reduced EF as HF p EF and HF r EF, respectively ( Table 3 ). ARBs are recommended in patients with HF r EF with current or prior symptoms who are ACE inhibitor intolerant, unless contraindicated, to reduce morbidity and mortality. N-terminal-pro-brain natriuretic peptide predicts outcome after hospital discharge in heart failure patients. When properly applied, expert analysis of available data on the benefits and risks of these therapies and procedures can improve the quality of care, optimize patient outcomes, and favorably affect costs by focusing resources on the most effective strategies. Nevertheless, the coexistence of additional diseases such as arthritis, renal insufficiency, diabetes mellitus, or chronic lung disease with the HF syndrome should logically require a modification of treatment, outcome assessment, or follow-up care. This document was approved for publication by the governing bodies of the ACCF and AHA and endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American College of Chest Physicians, Heart Rhythm Society, and International Society for Heart and Lung Transplantation. See Figure 2, indications for CRT therapy algorithm. Routine use of invasive hemodynamic monitoring is not recommended in normotensive patients with acute decompensated HF and congestion with symptomatic response to diuretics and vasodilators. In most patients, abnormalities of systolic and diastolic dysfunction coexist, irrespective of EF. Yancy, Mariell Jessup, Biykem Bozkurt, Javed Butler, Donald E. Although patients with a history of congenital heart disease have a low absolute risk of complications, they still remain at increased risk, caution researchers. See Table 11 for drugs commonly used for HF r EF (stage C HF). (Level of Evidence: C). Utility of amino-terminal pro-brain natriuretic peptide testing for prediction of 1-year mortality in patients with dyspnea treated in the emergency department. Studies are identified as observational, retrospective, prospective, or randomized where appropriate. A validated risk score for in-hospital mortality in patients with heart failure from the American Heart Association get with the guidelines program. Forfia PR, Watkins SP, Rame JE, et al. Plasma B-type natriuretic peptide levels in ambulatory patients with established chronic symptomatic systolic heart failure. 136,170,171,189 (Level of Evidence: A). Applying Classification of Recommendation and Level of Evidence. Initial and Serial Evaluation of the HF Patient: Recommendations 1817. Evidence Gaps and Future Research Directions1835 References 1837 Appendix 1. EF is considered important in classification of patients with HF because of differing patient demographics, comorbid conditions, prognosis, and response to therapies 36 and because most clinical trials selected patients based on EF. Until definitive therapy (eg, coronary revascularization, MCS, heart transplantation) or resolution of the acute precipitating problem, patients with cardiogenic shock should receive temporary intravenous inotropic support to maintain systemic perfusion and preserve end-organ performance. (Level of Evidence: C). Pfisterer M, Buser P, Rickli H, et al. For issues for which sparse data are available, a survey of current practice among the clinicians on the writing committee is the basis for LOE C recommendations and no references are cited. Low-dose dopamine infusion may be considered in addition to loop diuretic therapy to improve diuresis and better preserve renal function and renal blood flow. 22. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. A growing body of studies on patient-centered outcomes research is likely to address some of these deficiencies, but time will be required. See Table 23 for a summary of recommendations from this section. See Table 20 for inotropic agents used in HF management and Table 21 for a summary of recommendations from this section. (Level of Evidence: C). Screening the population for left ventricular hypertrophy and left ventricular systolic dysfunction using natriuretic peptides: results from the Dallas Heart Study. Additional other HF guideline statements are highlighted as well for the purpose of comparison and completeness. Stages in the development of HF and recommended therapy by stage. 125,126 (Level of Evidence: B). Oral Diuretics Recommended for Use in the Treatment of Chronic HF. Costanzo MR, Dipchand A, Starling R, et al. (Level of Evidence: C). Although there are additional and important comorbidities that occur in patients with HF as referenced in Table 24, it remains uncertain how best to generate specific recommendations, given the status of current evidence. Value of clinician assessment of hemodynamics in advanced heart failure: the ESCAPE trial. Implications of elevated cardiac troponin T in ambulatory patients with heart failure: a prospective analysis. Richards AM, Doughty R, Nicholls MG, et al. See Figure 3 for the stages in the development of HF. Butman SM, Ewy GA, Standen JR, et al. See Table 8 for a summary of recommendations from this section. Medscape editor-in-chief Eric Topol outlines the best technological advances in medicine of the last year. Endomyocardial biopsy should not be performed in the routine evaluation of patients with HF. This new term, GDMT, will be used herein and throughout all future guidelines. Both for GDMT and other recommended drug treatment regimens, the reader is advised to confirm dosages with product insert material and to evaluate carefully for contraindications and drug-drug interactions. Classification of patients presenting with acutely decompensated heart failure. Wedel H, McMurray JJ, Lindberg M, et al. Adapted with permission from Nohria et al. Routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is potentially harmful for patients with HF r EF. Additionally, the committee reviewed documents related to the subject matter previously published by the ACCF and AHA. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 317,318 ( Level of Evidence: B ). See Table 25 for a summary of recommendations from this section. Moe GW, Howlett J, Januzzi JL, et al. van Kimmenade RR, Pinto YM, Bayes-Genis A, et al. Addition of an ARB may be considered in persistently symptomatic patients with HF r EF who are already being treated with an ACE inhibitor and a beta blocker in whom an aldosterone antagonist is not indicated or tolerated. The writing committee saw no need to reiterate the recommendations contained in those guidelines and chose to harmonize recommendations when appropriate and eliminate discrepancies. Dr Melissa Walton-Shirley chose to hit the reset button and begin again in a new state to practice patient-first medicine. Despite these limitations, it is apparent that much can be done for HF. Triglycerides Fall in Phase 3 Trial of Novel Antisense Inhibitor. Advanced chronic heart failure: a position statement from the Study Group on Advanced Heart Failure of the Heart Failure Association of the European Society of Cardiology. Lainchbury JG, Troughton RW, Strangman KM, et al. Systolic and diastolic blood pressure should be controlled in patients with HF p EF in accordance with published clinical practice guidelines to prevent morbidity. The authors included general cardiologists, HF and transplant specialists, electrophysiologists, general internists, and physicians with methodological expertise. The medical profession should play a central role in evaluating the evidence related to drugs, devices, and procedures for the detection, management, and prevention of disease. Community screening for left ventricular systolic dysfunction using plasma and urinary natriuretic peptides. Heart failure incidence and survival (from the Atherosclerosis Risk in Communities study). T-Waves on ECG May Forecast Sudden Death Risk in Men. Post-MI Beta-blockers in Frail Elderly Up Survival, Lower QoL. Bettencourt P, Azevedo A, Pimenta J, et al. Changes in brain natriuretic peptide and norepinephrine over time and mortality and morbidity in the Valsartan Heart Failure Trial (Val-HeFT). N-terminal pro-B-type natriuretic peptide-guided, intensive patient management in addition to multidisciplinarycare in chronic heart failure: a 3-arm, prospective, randomized pilot study. An extensive evidence review was conducted through October 2011 and includes selected other references through April 2013. Although of increasing importance, children with HF and adults with congenital heart lesions are not specifically addressed in this guideline. TRUE-AHF: Better to Prevent vs Treat Acute Decompensation. 2). Performance measures based on professionally developed clinical practice guidelines should be used with the goal of improving quality of care for HF. In an effort to maintain relevance at the point of care for practicing clinicians, the Task Force continues to oversee an ongoing process improvement initiative. When available, information from studies on cost is considered, but data on efficacy and outcomes constitute the primary basis for the recommendations contained herein. GDMT is specifically referenced in the recommendations for treatment of HF (Section 6. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Clinical Events and Findings Useful for Identifying Patients With Advanced HF. To prevent sudden death, placement of an implantable cardioverter-defibrillator (ICD) is reasonable in patients with asymptomatic ischemic cardiomyopathy who are at least 40 days post-MI, have an LVEF of 30% or less, are on appropriate medical therapy, and have reasonable expectation of survival with a good functional status for more than 1 year. HF is a syndrome with a high prevalence of comorbidities and multiple chronic conditions, but most guidelines are developed for patients with a single disease.
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