2009 ACCF/AHA Heart Failure Guidelines

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2009 Focused Update: ACCF/AHA Guidelines for the

Diagnosis and Management of Heart Failure in Adults

ACC Heart Failure Guidelines

J. Am. Coll. Cardiol. April 14, 2009; 53;1343-1382Circulation. April 14, 2009;119;1977-2016

Class I Benefit >>> Risk

Procedure/ Treatment SHOULD be performed/ administered

Class IIa Benefit >> RiskAdditional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment

Class IIb Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Class III Risk ≥ BenefitNo additional studies needed

Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

Level A: Recommendation based on evidence from multiple randomized trials or meta-analyses Multiple (3-5) population risk strata evaluated; General consistency of direction and magnitude of effect

Level B: Recommendation based on evidence from a single randomized trial or non-randomized studies Limited (2-3) population risk strata evaluated

Level C: Recommendation based on expert opinion, case studies, or standard-of-care Very limited (1-2) population risk strata evaluated

shouldis recommendedis indicatedis useful/effective/

beneficial

is reasonablecan be useful/effective/

beneficialis probably recommended

or indicated

may/might be consideredmay/might be reasonableusefulness/effectiveness is

unknown /unclear/uncertain or not well established

is not recommendedis not indicatedshould notis not

useful/effective/beneficialmay be harmful

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Initial Clinical Assessment of Patients Presenting with Heart Failure

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In pts presenting with HF, initial assessment should be made of the pt’s ability to perform routine and desired activities of daily living.

Initial examination of pts presenting with HF should include assessment of volume status, orthostatic BP changes, measurement of weight and height, and BMI.

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Initial Assessment and Examination of Patients with HF


NO CHANGE

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Initial lab evaluation of pts presenting with HF should include CBC, urinalysis, electrolytes (including Ca and Mg), BUN, creatinine, fasting blood glucose (glycohemoglobin), lipid profile, LFT, and TSH.



12-lead ECG and CXR should be performed initially in all pts presenting with HF.

Initial Laboratory Evaluation


NO CHANGE

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2D echocardiography with Doppler should be performed during initial evaluation of pts presenting with HF to assess LVEF, LV size, wall thickness, and valve function.


Coronary arteriography should be performed in pts presenting with HF who have angina or significant ischemia unless the pt is not eligible for revascularization of any kind.


2D Echocardiography


Coronary Revascularization

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Coronary arteriography is reasonable for pts presenting with HF who have known or suspected CAD but who do not have angina unless the pt is not eligible for revascularization of any kind.

I IIa IIb III

Coronary Revascularization


Coronary arteriography is reasonable for pts presenting with HF who have chest pain that may or may not be of cardiac origin who have not had evaluation of their coronary anatomy and who have no contraindications to coronary revascularizations.

I IIa IIb III

NO CHANGE

NO CHANGE

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Measurement of BNP or N-terminal pro-BNP (NT-proNBP)) can be useful in the evaluation of pts presenting in the urgent care setting in whom the clinical diagnosis of HF is uncertain. Measurement of BNP can be helpful in risk stratification.

Noninvasive imaging may be considered to define the likelihood of CAD in pts with HF and LV dysfunction.

Measurement of BNP and Noninvasive Imaging



Modified

NO CHANGE


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Patients with Reduced Left Ventricular Ejection Fraction

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Measures listed as Class I recommendations for pts in Stages A and B are also appropriate for pts in Stage C.





Diuretics and salt restriction are indicated in pts with current or prior symptoms of HF and reduced LVEF who have evidence of fluid retention.

Measuring LVEF

NO CHANGE

NO CHANGE

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ACE inhibitors are recommended for all pts with current or prior symptoms of HF and reduced LVEF, unless contraindicated .


Use of beta blockers proven to reduce mortality (i.e., bisoprolol, carvedilol, and metoprolol) is recommended for all stable pts with symptoms of HF and reduced LVEF, unless contraindicated.


Measuring LVEF

Modified

NO CHANGE

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Angiotensin II receptor blockers are recommended in pt with symptoms of HF and reduced LVEF who are ACE-inhibitor intolerant.


Drugs known to adversely affect the clinical status of pts with symptoms of HF and reduced LVEF should be avoided or withdrawn whenever possible (e.g., NSAID, most antiarrhythmic drugs, and most CCB drugs).


Angiotensin ll Receptor Blockers

NO CHANGE

NO CHANGE

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ICD is recommended as secondary prevention to prolong survival in pts with of HF and reduced LVEF who have a history of cardiac arrest, VF, or hemodynamically destabilizing VT.


Secondary Prevention: Implantable Cardioverter-Defibrillator

NO CHANGE

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ICD is recommended for primary prevention of SCD to reduce total mortality in pts with non-ischemic DCM or IHD at least 40 days post-MI, have LVEF ≤ 35%, with NYHA Fc II or III while receiving chronic optimal medical therapy, and who have expectation of survival with good functional status > 1 year.



Primary Prevention: Implantable Cardioverter-Defibrillator

Modified

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Addition of an aldosterone antagonist is recommended in selected pts with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal K concentration. Creatinine ≤ 2.5 mg/dL in men or ≤ 2.0 mg/dL in women and K < 5.0 meq/L.



The Risks of Aldosterone Antagonists

NO CHANGE

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Recommendations for Atrial Fibrillation and Heart Failure

It is reasonable to treat pts with atrial fibrillation and HF with a strategy to maintain sinus rhythm or with a strategy to control ventricular rate alone.


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Digitalis can be beneficial in pts with symptoms of HF and reduced LVEF to decrease hospitalizations for HF.



The Benefits of Digitalis

NO CHANGE

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Hydralazine and Nitrate Combination

A combination of hydralazine and a nitrate might be reasonable in pts with symptoms of HF and reduced LVEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency.


NO CHANGE

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Long-term use of an infusion of a positive inotropic drug may be harmful and is not recommended for pts with current or prior symptoms of HF and reduced LVEF, except as palliation for pts with end-stage HF who cannot be stabilized with standard medical treatment.


Infusion of Positive Inotropic Drugs

NO CHANGE

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Patients with Heart Failure and Normal Left Ventricular Ejection Fraction

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Physicians should control systolic and diastolic hypertension in pts with HF and normal LVEF, in accordance with published guidelines.

Physicians should control ventricular rate in pts with HF and normal LVEF and atrial fibrillation.

Physicians should use diuretics to control pulmonary congestion and peripheral edema in pts with HF and normal LVEF.

Normal Left Ventricular Ejection Fraction




NO CHANGE

NO CHANGE

NO CHANGE

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Coronary revascularization is reasonable in pts with HF and normal LVEF and CAD in whom symptomatic or demonstrable myocardial ischemia is judged to be having an adverse effect on cardiac function.


I IIa IIb III

NO CHANGE

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Restoration and maintenance of sinus rhythm in pts with atrial fibrillation and HF and normal LVEF might be useful to improve symptoms.

The use of beta-blockers, ACEIs, ARBs, or CCB in pts with HF and normal LVEF and controlled hypertension might be effective to minimize symptoms of HF.

The usefulness of digitalis to minimize symptoms of HF in pts with HF and normal LVEF is not well established.





NO CHANGE

NO CHANGE

NO CHANGE

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Patient with Refractory End-Stage Heart Failure (Stage D)

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Meticulous identification and control of fluid retention is recommended in pts with refractory end-stage HF.


Referral for cardiac transplantation in potentially eligible pts is recommended for pts with refractory end-stage HF.

Referral of pts with refractory end-stage HF to an HF program with expertise in the management of refractory HF is useful.


Referral of Patients with Refractory End-Stage HF


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Patients with refractory end-stage HF and ICD should receive information about the option to inactivate defibrillation.


Options for end-of-life care should be discussed with the patient and family when severe symptoms in pts with refractory end-stage HF persist despite application of all recommended therapies.



Severe Symptoms in Patients With Refractory End-Stage HF

Consideration of an LVAD as permanent or “destination” therapy is reasonable in highly selected pts with refractory end-stage HF and an estimated 1-year mortality over 50% with medical therapy.


NO CHANGE

NO CHANGE

NO CHANGE

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Continuous IV infusion of a inotropic agent may be considered for palliation of symptoms in pts with refractory end-stage HF.


Continuous Intravenous Infusion of Positive Inotropic Agents


Partial left ventriculectomy is not recommended in pts with non-ischemic cardiomyopathy and refractory end-stage HF.

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIIRoutine intermittent infusions of vasoactive and inotropic agents are not recommended for pts with refractory end-stage HF.Modified

NO CHANGE

NO CHANGE

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Recommendations for the Hospitalized Patient

New Recommendations

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The diagnosis of HF is primarily based on signs and symptoms derived from a thorough history and physical exam.

Clinicians should determine the following:a. adequacy of systemic perfusion;b. volume status;c. contribution of precipitating factors and/or co-

morbidities d. if the heart failure is new onset or an

exacerbation of chronic disease; ande. whether it is associated with preserved normal or

reduced ejection fraction.

CXR, ECG, and echocardiography are key tests in this assessment.

The Hospitalized Patient

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BNP or NT-proBNP should be measured in pts being evaluated for dyspnea in which the contribution of HF is not known.

Final diagnosis requires interpreting these results in the context of all available clinical data and ought not to be considered a stand-alone test.



ACS precipitating HF hospitalization should be promptly identified by ECG and troponin, and treated, as appropriate to the overall condition and prognosis of the patient.


Patients Being Evaluated for Dyspnea

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It is recommended that the following common potential precipitating factors for acute HF be identified as recognition of these comorbidities, is critical to guide therapy:

• ACS/coronary ischemia• severe hypertension• atrial and ventricular arrhythmias• infections• pulmonary emboli• renal failure• medical or dietary non-compliance


III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIIPrecipitating Factors for Acute HF

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Oxygen therapy should be administered to relieve symptoms related to hypoxemia.


Whether the diagnosis of HF is new or chronic, pts who present with rapid decompensation and hypoperfusion associated with decreasing urine output and other manifestations of shock are critically ill and rapid intervention should be used to improve systemic perfusion.



Oxygen Therapy and Rapid Intervention

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Patients admitted with HF and with evidence of significant fluid overload should be treated with IV loop diuretics. Therapy should begin in ED or OPD without delay, as early intervention may be associated with better outcomes for pts hospitalized with decompensated HF.

If pts are already receiving loop diuretic therapy, the initial IV dose should equal or exceed their chronic oral daily dose. Urine output and signs and symptoms of congestion should be serially assessed, and diuretic dose should be titrated accordingly to relieve symptoms and to reduce extracellular fluid volume excess.


Treatment with Intravenous Loop Diuretics



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Effect of HF treatment should be monitored with careful measurement of fluid intake and output; vital signs; body weight, determined at the same time each day; clinical signs and symptoms of systemic perfusion and congestion.

Daily serum electrolytes, BUN, and creatinine should be measured during the use of IV diuretics or active titration of HF medications.



Monitoring and Measuring Fluid Intake and Output

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When diuresis is inadequate to relieve congestion, the diuretic regimen should be intensified using either:

a. higher doses of loop diuretics;b. addition of a second diuretic (such as

metolazone, spironolactone or IV chlorthiazide) or

c. Continuous infusion of a loop diuretic.

Intensifying the Diuretic Regimen

New

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Invasive hemodynamic monitoring should be performed to guide therapy in pts who are in respiratory distress or with clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment.

In pts with clinical evidence of hypotension associated with hypoperfusion and obvious evidence of elevated cardiac filling pressures (e.g., elevated jugular venous pressure; elevated PAWP), IV inotropic or vasopressor drugs should be administered to maintain systemic perfusion and preserve end-organ performance while more definitive therapy is considered.




Preserving End-Organ Performance

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In pts hospitalized with HF with reduced EF not treated with oral therapies known to improve outcomes, particularly ACE inhibitors or ARBs and beta-blocker therapy, initiation of these therapies is recommended in stable pts prior to hospital discharge.

Initiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of IV diuretics, vasodilators, and inotropic agents. Beta-blocker therapy should be initiated at a low dose and only in stable pts. Particular caution should be used when initiating beta-blockers in pts who have required inotropes during their hospital course.



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Urgent Cardiac Catheterization and Revascularization

When pts present with acute HF and known or suspected acute myocardial ischemia due to occlusive coronary disease, especially when there are signs and symptoms of inadequate systemic perfusion, urgent cardiac catheterization and revascularization is reasonable where it is likely to prolong meaningful survival.

I IIa IIb III

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In pts with evidence of severely symptomatic fluid overload in the absence of systemic hypotension, vasodilators such as IV NTG, nitroprusside or neseritide can be beneficial when added to diuretics and/or in those who do not respond to diuretics alone.


Severe Symptomatic Fluid Overload

I IIa IIb III

New

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Invasive hemodynamic monitoring can be useful for carefully selected pts with acute HF who have persistent symptoms despite empiric adjustment of standard therapies, and

a. whose fluid status, perfusion, or systemic or pulmonary vascular resistances are uncertain;

b. whose SBP remains low, associated with symptoms, despite initial therapy;

c. whose renal function is worsening with therapy;d. who require parenteral vasoactive agents; ore. who may need consideration for advanced

device therapy or transplantation.


I IIa IIb III

Invasive Hemodynamic Monitoring

New

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Ultrafiltration is reasonable for pts with refractory congestion not responding to medical therapy.


III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIIIV inotropic drugs such as dopamine, dobutamine or milrinone might be reasonable for those pts presenting with documented severe systolic dysfunction, low BP and evidence of low cardiac output, with or without congestion, to maintain systemic perfusion and preserve end-organ performance.

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2009 ACCF/AHA Heart Failure Guidelines