2017 ACLS Focused Update Takeaways - Management of Heart Failure
The information for the following review was obtained from the 2017 ACC/AHA/HFSA focused update on guidelines for the management of heart failure. The material was reviewed and published in the August 2017 edition of Circulation.
This focused referenced revision is the second part of the heart failure update. The first section was the “2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure.”
ACC/AHA Recommendation System: Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015)
The topics presented in the review were:
- Biomarkers (for prevention, diagnosis, and prognosis of heart failure)
- The treatment of stages A to D (to include pharmacological treatment for Stage C heart failure (HF) with reduced ejection fraction (rEF), recommendations for ivabradine, pharmacological treatment for Stage C HF with preserved ejection fraction (pEF)
- Anemia recommendations
- Sleep-disordered breathing
Assays for BNP (B-type natriuretic peptide) and NTproBNP (N-terminal pro-B-type natriuretic peptide), which are both natriuretic peptide biomarkers, have been used increasingly to establish the presence and severity of HF. A substantial evidence base exists that supports the use of natriuretic peptide biomarkers to assist in the diagnosis or exclusion of HF as a cause of symptoms (eg, dyspnea, weight gain) in the setting of chronic ambulatory HF or in the setting of acute care with decompensated HF, especially when the cause of dyspnea is unclear.
Cardiac troponin levels may be elevated in the setting of chronic or acute decompensated HF, suggesting myocyte injury or necrosis. Troponins I and T respond similarly for acute coronary syndromes and acute decompensated HF. Elevations in either troponin I or T levels in the setting of acute HF are of prognostic significance and must be interpreted in the clinical context.
Biomarkers for Prevention: Recommendation
For patients at risk of developing HF, natriuretic peptide biomarker-based screening followed by team-based care, including a cardiovascular specialist optimizing GDMT, can be useful to prevent the development of left ventricular dysfunction (systolic or diastolic) or new-onset HF (Class IIa; Level B-R).
Biomarkers for Diagnosis: Recommendation
In patients presenting with dyspnea, measurement of natriuretic peptide biomarkers is useful to support a diagnosis or exclusion of HF (Class I; Level A).
Biomarkers for Prognosis or Added Risk Stratification: Recommendations
Measurement of BNP or NT-proBNP is useful for establishing prognosis or disease severity in chronic HF (Class I; Level A).
Measurement of baseline levels of natriuretic peptide biomarkers and/or cardiac troponin on admission to the hospital is useful to establish a prognosis in acutely decompensated HF (Class I; Level A).
During a HF hospitalization, a pre-discharge natriuretic peptide level can be useful to establish a post-discharge prognosis (Class IIa; Level B-NR).
In patients with chronic HF, measurement of other clinically available tests, such as biomarkers of myocardial injury or fibrosis, may be considered for additive risk stratification (Class IIb; Level B-NR).
Pachal, et al; e143
The treatment of stages A to D (to include pharmacological treatment for Stage C heart failure (HF) with reduced ejection fraction (rEF), recommendations for ivabradine, pharmacological treatment for Stage C HF with preserved ejection fraction (pEF)
The recommendations for Renin-Angiotensin system inhibition with an ACE inhibitor or ARB or ARNI are summarized in our 2016 Focused Update Takeaways.
Recommendations for ivabradine
Ivabradine is a new therapeutic agent that selectively inhibits the IF current in the sinoatrial node, providing heart rate reduction. The benefit of ivabradine was driven by a reduction in HF hospitalization. The target of ivabradine is heart rate slowing (the presumed benefit of action). Given the well-proven mortality benefits of beta-blocker therapy, it is important to initiate and up titrate these agents to target doses, as tolerated, before assessing the resting heart rate for consideration of ivabradine initiation.
Ivabradine can be beneficial to reduce HF hospitalization for patients with symptomatic (NYHA class II-III) stable chronic HFrEF (LVEF ≤35%) who are receiving guideline-directed management and therapy (GDMT), including a beta blocker at maximum tolerated dose, and who are in sinus rhythm with a heart rate of 70 bpm or greater at rest (Class IIa; Level B-R).
Recommendations for Stage C HFpEF
Systolic and diastolic blood pressure should be controlled in patients with HFpEF in accordance with published clinical practice guidelines to prevent morbidity (Class I; Level B).
Diuretics should be used for relief of symptoms due to volume overload in patients with HFpEF (Class I; Level C).
Coronary revascularization is reasonable in patients with CAD in whom symptoms (angina) or demonstrable myocardial ischemia is judged to be having an adverse effect on symptomatic HFpEF despite GDMT (Class IIa; Level C).
Management of AF according to published clinical practice guidelines in patients with HFpEF is reasonable to improve symptomatic HF (Class IIa; Level C).
The use of beta-blocking agents, ACE inhibitors, and ARBs in patients with hypertension is reasonable to control blood pressure in patients with HFpEF (Class IIa; Level C).
In appropriately selected patients with HFpEF (with EF ≥45%, elevated BNP levels or HF admission within 1 year, estimated glomerular filtration rate >30 mL/min, creatinine <2.5 mg/dL, potassium <5.0 mEq/L), aldosterone receptor antagonists might be considered to decrease hospitalizations (Class IIb; Level B-R).
The use of ARBs might be considered to decrease hospitalizations for patients with HFpEF (Class IIb; Level B).
Routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or QoL in patients with HFpEF is ineffective (Class III: No benefit; Level B-R).
Routine use of nutritional supplements is not recommended for patients with HFpEF (Class III: No benefit; Level C).
In patients with NYHA class II and III HF and iron deficiency (ferritin <100 ng/mL or 100 to 300 ng/mL if transferrin saturation is <20%), intravenous iron replacement might be reasonable to improve functional status and QoL (Class IIb; Level B-R).
In patients with HF and anemia, erythropoietin-stimulating agents should not be used to improve morbidity and mortality (Class III: No benefit; Level B-R).
Treating Hypertension to Reduce the Incidence of HF: Recommendation
In patients at increased risk, stage A HF, the optimal blood pressure in those with hypertension should be less than 130/80 mm Hg (Class I; Level B-R).
Treating Hypertension in Stage C HFrEF: Recommendation
Patients with HFrEF and hypertension should be prescribed GDMT titrated to attain systolic blood pressure less than 130 mm Hg (Class I; Level C-EO).
Sleep-Disordered Breathing: Recommendations
In patients with NYHA class II–IV HF and suspicion of sleep-disordered breathing or excessive daytime sleepiness, a formal sleep assessment is reasonable (Class IIa; Level C-LD).
In patients with NYHA class II–IV HF and suspicion of sleep-disordered breathing or excessive daytime sleepiness, a formal sleep assessment is reasonable (Class IIb; Level B-R).
In patients with NYHA class II–IV HFrEF and central sleep apnea, adaptive servo-ventilation causes harm (Class III: Harm; Level B-R).
- ACE = angiotensin-converting enzyme
- ARB = angiotensin-receptor blocker
- ARNI = angiotensin receptor–neprilysin inhibitor
- BNP = B-type natriuretic peptide
- BP = blood pressure
- COR = Class of Recommendation
- CPAP = continuous positive airway pressure
- EF = ejection fraction
- GDMT = guideline-directed management and therapy
- HFpEF = heart failure with preserved ejection fraction
- HFrEF = heart failure with reduced ejection fraction
- LOE = Level of Evidence
- LVEF = left ventricular ejection fraction
- NT-proBNP = N-terminal pro-B-type natriuretic peptide
- QoL = quality of life
- RCT = randomized controlled trial
- Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Colvin MM, Drazner MH, Filippatos GS, Fonarow GC, Givertz MM, Hollenberg SM, Lindenfeld J, Masoudi FA, McBride PE, Peterson PN, Stevenson LW, Westlake C. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017;136:e137– e161. DOI: 10.1161/CIR.0000000000000509.