Heart Failure Guidelines: A Dynamic Document
Pub Date: Thursday, March 26, 2009
Author: John B. O'Connell, MD, FAHA
Jessup M, Abraham WT, Casey DE, et al., writing on behalf of the 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult Writing Committee. 2009 Focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009. Published online before print March 26, 2009. 10.1161/CIRCULATIONAHA.109.192064.
Since 1995, the American College of Cardiology and the American Heart Association have jointly published guidelines on heart failure (HF). In the second rendition in 2001, the guidelines classified HF based on the stage of the illness, with stage A and B denoting preclinical disease, allowing for recommendations for prevention as well as treatment. The rapid evolution of evidence-based therapy communicated via scientific publications and late breaking clinical trials presentations necessitate a dynamic process to update this valuable document. In an effort to stay current, rather than convening the committee to rewrite this extensive tome, the Task Force on Practice Guidelines opted to provide a focused update for 2008. This update provides a means of more rapidly adopting evolving evidence and expert opinion into a more current document. This update is much easier to navigate due to superb tables that emphasize revisions that allow readers to stay current with the field. This brief commentary summarizes the importance of the changes introduced in the update as compared to the 2005 guidelines.
New information has been added regarding biomarkers, namely B-type natriuretic peptide (BNP), use of the fixed combination of hydralazine and isosorbide dinitrate (HYD/ISDN) in self-described African Americans, updates on the application of implantable cardioverter/defibrillators (ICDs) and cardiac resynchronization therapy (CRT), use of inotropes and vasodilators in acute and chronic HF, and a discussion of rate versus rhythm control in atrial fibrillation. A very helpful new section has been added to the document that provides an important discussion regarding the management of HF in the hospitalized patient that previously had not been extensively addressed. New updates will be forthcoming as needed. It should be noted that the purpose of the guidelines is only to assist providers in clinical decision making and should not be perceived as a strict algorithm for the management of this complex medical condition.
The important role of BNP as a diagnostic aid as well as a support in risk stratification is emphasized and added as an IIa recommendation. Many HF specialists rely heavily on the initial BNP for diagnostic assistance and to guide intensivity of medical therapy. The African American Heart Failure Trial (A-HeFT) has provided justification for a recommendation of HYD/ISDN in self-described African Americans with moderate to severe HF on ACEI/ARBs and beta blockers as a Class I, level of evidence B recommendation. The guidelines for ICDs and CRT were adjusted to reflect new information but, also, to be consistent with the American College of Cardiology/American Heart Association (ACC/AHA) Heart Rhythm Society 2008 device-based therapy guidelines. In particular, the ICD guidelines have been simplified with the hope of greater appropriate application of this technology to prevent sudden cardiac death. This section has an in depth discussion of the complexity of this recommendation. The guidelines have also added statements regarding the strategy of management of atrial fibrillation in the HF patient. Either rate or rhythm control may be appropriate depending on the clinical circumstances and the response to drug therapy. In the section on stage D HF, the committee strongly discourages the chronic use of intermittent inotropes and vasoactive agents (specifically nesiritide), giving a class III, level of evidence A, recommendation, indicating use is not helpful and probably harmful. However, there remains a distinction between intermittent and continuous use because some patients may not be weanable and need the support either as palliation or in preparation for a heart transplant or mechanical circulatory support.
The most interesting section, which goes far beyond fine tuning, is the new section entitled "The Hospitalized Patient." Hospitals are struggling throughout the United States to deal with the growing burden of the HF patient, which is a major source of cost. Reducing the chaos of acute HF management will have a significant impact and will facilitate the compliance with the Joint Commission/Center for Medicare and Medicaid Services core measures and promote the organization necessary to develop the Get With The Guidelines Program of the AHA. While the European Society of Cardiology and the Heart Failure Society of America have published guidelines for the management of acutely decompensated HF, the ACC/AHA guidelines committee has not previously elaborated on this problem. The Update has 17 class I, four class IIa, one class IIb and two class III recommendations. The rationale for excluding such a comprehensive discussion in the past has been the lack of evidence base. In fact, of the 24 total recommendations, only one is level of evidence A! Although some have called such recommendations "eminence-based," until there are randomized controlled clinical trials to justify the recommendations, the quality of expertise on the panel and their collective experience justifies consensus recommendations. Because CMS has already developed core measures (three of which are incorporated into the recommendations in this document), the ACC/AHA committee should take a leadership role in defining best practice. The recommendations encompass diagnosis and treatment options in a stepwise approach that is easy to incorporate into clinical practice. It also addresses transition from inpatient to outpatient/home care. The guidelines address the role of invasive hemodynamic monitoring, coronary angiography, and ultrafiltration. It also provides for the up titration and/or initiation of neurohormonal antagonists.
Guidelines are designed as a tool to assist the provider and do not serve as a substitute for direct patient care. When used as an algorithm by outside agencies that have never had contact with the patient, as in some failed chronic disease management programs, the ability to judge the need for intensification of therapy may be lacking. Direct patient contact allows the provider to determine when to implement the recommendations in the guideline. As an example, the guideline emphasizes that signs of hypoperfusion and volume overload dictate the intensity of medical therapy. Detection of these signs usually requires direct patient contact. Therefore, guidelines should not take providers away from the patient but can only be properly implemented when clues from the bedside are taken into account. The ACC/AHA committee should be congratulated for their efforts to collate a rapidly growing literature and support the provision of high quality care to the HF patient.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association