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What are the recommendations found in the 2009 focused update to the American College of Cardiology Foundation/American Heart Association heart failure guidelines?
Introduction
Recently the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA), in collaboration with the International Society for Heart and Lung Transplantation published a focused update to their guidelines for the diagnosis and management of heart failure (HF) in adults.1 This update is not a full literature review but rather focuses on clinically significant data published since the 2005 guidelines were released. The new document provides key updates in several areas including the use of hydralazine and isosorbide dinitrate, implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT), treatment goals in patients with both HF and atrial fibrillation (AF), and a new section devoted to the management of hospitalized patients. Key highlights from the 2009 focused update to the HF guidelines are summarized below. Clinicians are encouraged to review the full document at http://www.acc.org or http://my.americanheart.org.
Hydralazine/Nitrates
African Americans with New York Heart Association (NYHA) functional class III or IV HF despite standard therapy [diuretics, angiotensin converting enzyme (ACE) inhibitors, and/or beta-blockers] who were placed on hydralazine and isosorbide dinitrate were found to have an improved survival rate compared to patients on standard therapy alone.1 The combination of hydralazine/nitrates should not be used in ACE inhibitor-naïve patients or as a substitute for ACE inhibitors in patients who are already taking them. However, the combination may be an option in patients who are intolerant to ACE-inhibitors (e.g. renal insufficiency, angioedema). According to the guidelines, the combination of hydralazine and nitrates is recommended to improve outcomes for African-Americans with moderate to severe HF despite therapy with ACE-inhibitors, beta-blockers, and diuretics. The addition of this combination in non-African-American patients with moderate to severe HF despite standard therapy is also a reasonable choice.
Cardiac Resynchronization Therapy/Implantable Cardioverter Defibrillator
Patients who are in normal sinus rhythm with a QRS duration ≥0.12 seconds and have a left ventricular ejection fraction (LVEF) ≤35%, New York Heart Association NYHA class III or ambulatory class IV symptoms despite maximal medication therapy should receive CRT with or without an ICD, unless contraindicated.1 Patients who fit the criteria above but are in AF should also be considered for CRT with or without an ICD. Cardiac resynchronization therapy should also be considered in patients with frequent dependency on ventricular pacing. Implantation of an ICD is recommended for primary prevention of sudden cardiac death in patients who meet the following criteria; 1) non-ischemic dilated cardiomyopathy or ischemic heart disease at least 40 days post-myocardial infarction, 2) LVEF ≤35%, 3) NYHA functional class II or III while receiving chronic standard therapy, and 4) reasonable expectation of survival with a good functional status for more than 1 year.
Atrial Fibrillation
The guidelines state that it is reasonable to control heart rate alone or to maintain sinus rhythm in patients with AF and HF.1 The target resting heart rate should be less than 80 to 90 beats per minute and should not exceed 110 to 130 beats per minute during moderate exercise. Patients with HF and AF should be anticoagulated with warfarin, unless contraindicated, regardless of whether they are in sinus rhythm or not. This is due to the high recurrence rate of AF and high embolic risk in this population. Most HF patients who have electrical or chemical cardioversion will revert back to AF unless an antiarrhythmic is used to maintain sinus rhythm. Class I antiarrhythmics should generally be avoided in HF. Class III antiarrhythmics can be used in patients with HF to maintain sinus rhythm but are associated with systemic toxicity (amiodarone) and proarrhythmias (dofetilide).
The Hospitalized Patient
The focused update includes a new section with recommendations for the hospitalized patient.1
Three clinical scenarios generally describe how patients with HF present to a healthcare provider; 1) with a syndrome of decreased exercise tolerance 2) with a syndrome of fluid retention 3) with no symptoms or symptoms of another cardiac or noncardiac disorder. The diagnosis of HF in the hospitalized patient should be based on signs and symptoms. Clinicians should determine the adequacy of systemic perfusion, volume status, new onset versus an exacerbation of chronic HF, and whether the exacerbation is associated with preserved LVEF. The contribution of precipitating factors and/or comorbidities should also be weighed in order to understand the cause of acute symptoms. Chest radiograph, electrocardiogram (ECG), echocardiogram (ECHO), and B-type natiuretic peptide (BNP) or N-terminal pro-B natiuretic peptide (NT-proBNP) should be used in assessing the patient with HF. B-type natiuretic peptide and NT-proBNP should be used to help evaluate dyspnea but should not be used as the sole means to diagnose HF. Recognizing potential precipitating factors (e.g. acute coronary syndromes, severe hypertension, arrhythmias, infection, pulmonary emboli, renal failure, and medical/dietary nonadherence) is critical in guiding HF management.
Most hypertensive patients admitted for HF should have their antihypertensive regimen continued and even uptitrated if needed.1 Most patients on a beta-blocker can and should continue therapy when hospitalized for HF as studies have shown they improve outcomes. Reducing beta-blocker doses or withholding therapy should be reserved for cases of marked volume overload or in cases where hospitalization occurred shortly after initiation or uptitration. Withholding or reducing doses of an ACE inhibitor, angiotensin receptor blocker (ARB) and/or aldosterone antagonist should be considered in patients with worsening renal function. Increasing doses of beta-blockers or ACE-inhibitors in a decompensated patient may interfere with measures to relieve congestion. However, evidence based medications should be instituted prior to the patient leaving the hospital. Beta-blockers should be initiated at low doses in stable patients who have had their volume status optimized. However, extra caution should be exercised when initiating a beta-blocker in patients who required inotropes during hospitalization. ACE-inhibitors should be used cautiously in patients with marked azotemia.
Patients with marked volume overload will require intravenous (IV) diuretics, uptitration of oral diuretics, and/or addition of another diuretic.1 Ideally, an IV diuretic should be started without delay in the emergency department. Administering adequate doses of diuretics to achieve adequate diuresis without causing orthostasis and/or renal dysfunction is vital to caring for the hospitalized patient with HF. Patients who fail to respond to IV diuretics should be considered for assessment of ventricular filling pressures and cardiac output via a right heart catheterization. Measures recommended to overcome diuretic resistance include increasing the diuretic dose, adding a second diuretic (e.g. metolazone, IV chlorothiazide, or spironolactone), or changing to a continuous infusion of a loop diuretic. If these strategies fail, ultrafiltration or other renal replacement strategies may be appropriate. A physical exam, body weight, supine and standing vital signs, fluid input/output, and assessment of electrolytes and renal function should be performed daily.
Intravenous vasodilators (e.g. nitroprusside, nitroglycerin, nesiritide) may be added to the HF regimen in patients with adequate blood pressure and continued congestion despite diuretics and standard therapy.1 The goals of adding vasodilators are to more rapidly resolve fluid overload, relieve angina symptoms while awaiting coronary intervention, and to control hypertension which may be worsening HF symptoms. However, the use of vasodilators cannot be generalized, and providers must be certain the patient’s intravascular volume is expanded, and blood pressure will tolerate the medication.
Dopamine, dobutamine, or milrinone may be considered for patients with low output syndrome or congestion with low output.1 These inotropes help relieve symptoms associated with HF and tend to have the greatest benefit in patients with hypotension and intolerance or no response to vasodilation or diuretics. However, their use is associated with a poor prognosis. The decision to use these agents should not be based on a specific blood pressure but rather a decreased blood pressure with signs of poor cardiac output and/or hypoperfusion (e.g. cool extremities, decrease urine output, altered mental status). Dobutamine may not be the best option in patients on a beta-blocker as it needs the beta receptor for its inotropic effects. Milrinone does not require the beta receptor, and it has vasodilating properties for both systemic and pulmonary circulation. Regardless of which inotrope is chosen, patients must be carefully selected and closely monitored.
Hospital Discharge
Communication regarding the plan after hospital discharge should be relayed to the patient, his/her family, and the patient’s primary care physician.1 The discharge plan should address activity level, diet, discharge medications, follow up appointment(s), weight monitoring, and what to do if symptoms worsen. Patients and their families must be educated regarding the causes of HF, prognosis, therapy, dietary restrictions, activity, importance of compliance, and signs and symptoms of recurrent HF. Medication reconciliation should be done prior to admission and upon discharge. The importance of adherence to medications should be emphasized to the patient, and providers should focus on titration of standard medications to target doses whenever possible. Unfortunately, patients are commonly discharged home without adequate diuresis, blood pressure control, heart rate control, and essential medications (e.g. ACE-inhibitors, beta-blockers, etc). Discharge planning and post-discharge support in elderly patients with HF can reduce readmission rates and may improve morbidity and mortality.
Reference
- Jessup M, Abraham WT, Casey DE, et al. 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: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009;119(14):1977-2016.
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