Download Heart Failure — Summary of Medical Guidelines

Heart Failure — Summary of Medical Guidelines
Heart Failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.
The cardinal manifestations of HF are dyspnea and fatigue, which may limit exercise tolerance, and fluid retention, which may lead to pulmonary congestion and peripheral edema.
Stages in the development of
heart failure and recommended
therapy by stage
A - At high risk for HF but without structural
heart disease or symptoms of HF
B - Structural heart disease but without
signs or symptoms of HF
C - Structural heart disease with prior or
current symptoms of HF
D - Refractory HF requiring specialized
interventions
Therapeutic interventions in each stage
are aimed at modifying risk factors (stage
A), treating structural heart disease (stage
B), and reducing morbidity and mortality
(stages C and D).
Reprinted with permission
Circulation.2013;128:e240-e327
©2013, American Heart
Association, Inc.
ACEI indicates angiotensin-converting enzyme inhibitor; AF, atrial fibrillation; ARB, angiotensin-receptor blocker; CAD, coronary artery disease; CRT, cardiac
resynchronization therapy; DM, diabetes mellitus; EF, ejection fraction; GDMT, guideline-directed medical therapy; HF, heart failure; HFpEF, heart failure with preserved
ejection fraction; HFrEF, heart failure with reduced ejection fraction; HRQOL, health-related quality of life; HTN, hypertension; ICD, implantable cardioverter-defibrillator; LV, left
ventricular; LVH, left ventricular hypertrophy; MCS, mechanical circulatory support; and MI, myocardial infarction.
© 2015 Alere. All rights reserved.
Revised January 2015
Heart Failure — Summary of Medical Guidelines
Treatment Recommendations:
Stage A
1. Decrease risk of HF by:
1,2
· control hypertension and lipid disorders as recommended by guidelines
· obesity and diabetes mellitus should be controlled
· tobacco use and known cardiotoxic agents should be controlled or avoided
· Avoid cocaine and amphetamines; counsel patients about their alcohol intake
Stage B
COR
LOE
In patients with a history of MI and reduced EF, ACE inhibitors or ARBs
should be used to prevent HF
I
A
In patients with MI and reduced EF, evidence-based beta blockers should be used to prevent HF
I
B
In patients with MI, statins should be used to prevent HF
I
A
Blood pressure should be controlled to prevent symptomatic HF
I
A
ACE inhibitors should be used in all patients with a reduced EF to prevent HF
I
A
Beta blockers should be used in all patients with a reduced EF to prevent HF
I
C
IIa
B
III: Harm
C
An ICD is reasonable in patients with asymptomatic ischemic cardiomyopathy who are at least 40 d post-MI,
have an LVEF ≤30%, and on GDMT
Nondihydropyridine calcium channel blockers may be harmful in patients with low LVEF
ACE indicates angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; COR, Class of Recommendation; EF, ejection fraction; GDMT, guideline directed medical
therapy; HF, heart failure; ICD, implantable cardioverter-defibrillator; LOE, Level of Evidence; LVEF, left ventricular ejection fraction; MI, myocardial infarction; and N/A, not
available.
In general, all recommendations for patients with stage A HF also apply to those with stage B HF, particularly with respect to control of
blood pressure and the optimization of lipids with statins. CAD is a major risk factor for the development of HF and a key target for
prevention of HF. Long-term treatment of both systolic and diastolic hypertension reduces the risk of moving from stage A or B to stage
C HF.
Reprinted with permission
Circulation.2013;128:e240-e327
©2013, American Heart Association, Inc.
Sodium restriction is reasonable for patients with symptomatic HF to reduce congestive symptoms (IIa, C).
·
The AHA recommendation for restriction of sodium to 1500 mg/d appears to be appropriate for most patients with stage A and B HF.
1
The 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults (JNC 8) recommends:
o
treat to 150/90 mm Hg in patients over age 60
o
treat to 140/90 for patients <60 years or >18 years with either chronic kidney disease (CKD) or diabetes
2
The 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults (ATP 4) does not recommend treating to r specific LDL-cholesterol or
non-HDL targets for primary or secondary prevention of atherosclerotic cardiovascular disease. Based on risk (see 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk), moderate or
high intensity statin therapy may be instituted to achieve relative reductions in LDL cholesterol.
© 2015 Alere. All rights reserved.
Revised January 2015
Heart Failure — Summary of Medical Guidelines
Stage C
Nonpharmacological Interventions
Patients with HF should receive specific education to facilitate HF self-care.
Treatment of Sleep Disorders
·
Continuous positive airway pressure can be beneficial to increase LVEF and improve functional
status in patients with HF and sleep apnea.
Activity, Exercise Prescription
·
Exercise training (or regular physical activity) is recommended as safe and effective for patients
with HF who are able to participate to improve functional status.
Cardiac Rehabilitation
·
Cardiac rehabilitation can be useful in clinically stable patients with HF to improve functional
capacity, exercise duration, HRQOL, and mortality.
Pharmacological Treatment
Measures listed as Class I recommendations for patients in stages A and B are recommended where
appropriate for patients in stage C.
GDMT (guideline-directed medical therapy) as depicted in Figure 1 should be the mainstay of
pharmacological therapy for HFrEF
COR
I
IIa
LOE
B
B
I
A
IIa
B
I
(A, B, C)
I
A
Figure 1. Stage C HFrEF: evidence-based, guideline-directed medical therapy. ACEI indicates angiotensin-converting enzyme
inhibitor; ARB, angiotensin-receptor blocker; HFrEF, heart failure with reduced ejection fraction; Hydral-Nitrates, hydralazine and
isosorbide dinitrate; LOE, Level of Evidence; and NYHA, New York Heart Association.
Reprinted with permission
Circulation.2013;128:e240-e327
©2013, American Heart Association, Inc.
© 2015 Alere. All rights reserved.
Revised January 2015
Heart Failure — Summary of Medical Guidelines
Recommendations for Treatment of HFpEF
COR
LOE
Systolic and diastolic blood pressure should be controlled according to published clinical
I
B
practice guidelines
Diuretics should be used for relief of symptoms due to volume over
I
C
Coronary revascularization for patients with CAD in whom angina or demonstrable myocardial
IIa
C
ischemia is present despite GDMT
Management of AF according to published clinical practice guidelines for HFpEF to improve
IIa
C
symptomatic HF
Use of beta-blocking agents, ACE inhibitors, and ARBs for hypertension in HFpEF
IIa
C
ARBs might be considered to decrease hospitalizations in HFpEF
IIb
B
Nutritional supplementation is not recommended in HFpEF
III: no benefit
C
ACE indicates angiotensin-converting enzyme; AF, atrial fibrillation; ARBs, angiotensin-receptor blockers; CAD, coronary artery
disease; COR, Class of Recommendation; GDMT, guideline-directed medical therapy; HF, heart failure; HFpEF, heart failure with
preserved ejection fraction; and LOE, Level of Evidence.
Reprinted with permission
Circulation.2013;128:e240-e327
©2013, American Heart Association, Inc.
Additional recommendations:
·
Social Support: Social support is thought to buffer stress and promote treatment adherence and a
healthy lifestyle
·
Weight Loss: Although there are anecdotal reports about symptomatic improvement after weight
reduction in obese patients with HF, large-scale clinical trials on the role of weight loss in patients
with HF with obesity have not been performed.
Sodium restriction is reasonable for patients with symptomatic HF to reduce congestive symptoms.
·
For patients with stage C and D HF, currently there are insufficient data to endorse any specific
level of sodium intake. Because sodium intake is typically high (>4 g/d) in the general population,
clinicians should consider some degree (eg, <3 g/d) of sodium restriction in patients with stage C
and D HF for symptom improvement.
COR
-
LOE
-
IIa
C
Strategies for Achieving Optimal GDMT (guideline-directed medical therapy)
1. Uptitrate in small increments to the recommended target dose or the highest tolerated dose for those medications listed in Table 15 with an appreciation that some patients cannot
tolerate the full recommended doses of all medications, particularly patients with low baseline heart rate or blood pressure or with a tendency to postural symptoms.
2. Certain patients (eg, the elderly, patients with chronic kidney disease) may require more frequent visits and laboratory monitoring during dose titration and more gradual dose
changes. However, such vulnerable patients may accrue considerable benefits from GDMT. Inability to tolerate optimal doses of GDMT may change after disease-modifying
interventions such as CRT.
3. Monitor vital signs closely before and during uptitration, including postural changes in blood pressure or heart rate, particularly in patients with orthostatic symptoms, bradycardia,
and/or “low” systolic blood pressure (eg, 80 to 100 mm Hg).
4. Alternate adjustments of different medication classes (especially ACE inhibitors/ARBs and beta blockers) listed in Table 15. Patients with elevated or normal blood pressure and
heart rate may tolerate faster incremental increases in dosages.
5. Monitor renal function and electrolytes for rising creatinine and hyperkalemia, recognizing that an initial rise in creatinine may be expected and does not necessarily require
discontinuation of therapy; discuss tolerable levels of creatinine above baseline with a nephrologist if necessary.
6. Patients may complain of symptoms of fatigue and weakness with dosage increases; in the absence of instability in vital signs, reassure them that these symptoms are often transient
and usually resolve within a few days of these changes in therapy.
7. Discourage sudden spontaneous discontinuation of GDMT medications by the patient and/or other clinicians without discussion with managing clinicians.
8. Carefully review doses of other medications for HF symptom control (eg, diuretics, nitrates) during uptitration.
9. Consider temporary adjustments in dosages of GDMT during acute episodes of noncardiac illnesses (eg, respiratory infections, risk of dehydration, etc).
10. Educate patients, family members, and other clinicians about the expected benefits of achieving GDMT, including an understanding of the potential benefits of myocardial reverse
remodeling, increased survival, and improved functional status and HRQOL.
ACE indicates angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; CRT, cardiac resynchronization therapy; GDMT, guideline-directed medical therapy;
HF, heart failure; and HRQOL, health-related quality of life.
Source: Yancy CW, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240–e327. Available at
http://circ.ahajournals.org/content/128/16/e240.full.pdf+html
© 2015 Alere. All rights reserved.
Revised January 2015