The American College of Cardiology (ACC) and the American Heart Association (AHA) have released updated guidelines on the diagnosis and management of chronic heart failure in adults. guidelines discuss the recommended treatment options for patients based on the 4 stages of heart failure. Patients in Stage A or B are at risk for developing heart failure, whereas those in Stage C or D have documented signs or symptoms of the disease.
The new recommendations stress the importance of early recognition and treatment of risk factors such as hypertension, diabetes, and coronary artery disease in an attempt to prevent or delay the development of heart failure.
Additionally, the updated guideline has officially altered the name of the condition from “congestive heart failure” to “heart failure” because many patients with the disease do not present with congestive symptoms.
These guidelines were published in the September 20, 2005 issue of Circulation and are currently available on the ACC website at www.acc.org
Stage A High risk for developing heart failure
Patients at high-risk for heart failure should be counseled to avoid smoking, illicit drug use, and excessive alcohol consumption.
For patients with diabetes, glucose should be controlled.
A noninvasive evaluation of left ventricular function should be performed in patients with a strong family history of cardiomyopathy or in patients receiving cardiotoxic interventions.
Angiotensin converting enzyme inhibitors (ACEIs) (1st choice) or angiotensin II receptor blockers (ARBs) (2nd choice) can be useful to prevent heart failure in patients with risk factors
Stage B cardiac structural abnormalities
Patients with cardiac structural abnormalities or remodeling who have not developed symptomatic heart failure
Beta-blockers and ACEIs should be used in all patients with a history of myocardial infarction (MI) regardless of ejection fraction or presence of heart failure symptoms.
For patients who have not experienced an MI but have a reduced ejection fraction and no symptoms of heart failure, a beta-blocker and ACEI are recommended.
Treatment with an ARB is recommended for patients who are ACEI intolerant.
Coronary revascularization or valve replacement should be recommended for patients with significant disease.
An ACEI or ARB can be beneficial for patients with hypertension and left ventricular hypertrophy without any heart failure symptoms.
Placement of an implantable cardioverter-defibrillator (ICD) is reasonable for patients with ischemic cardiomyopathy who are at least 40 days post-MI, have a left ventricular ejection fraction of 30% or less, and are in New York Heart Association (NYHA) Class I.
Placement of an implantable ICD is also reasonable for patients with nonischemic cardiomyopathy who have a left ventricular ejection fraction of 30% or less, and are in NYHA Class I.
Stage C: Current/Prior Symptoms of Heart Failure
Bisoprolol, carvedilol, or sustained release metoprolol succinate are recommended for all stable patients with current or prior symptoms of heart failure and left ventricular ejection fraction.
Treatment with an ARB, specifically candesartan or valsartan, is recommended for patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction who are intolerant of an ACEI.
Exercise training is beneficial as an adjunctive treatment approach in patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction.
ICD therapy should be considered in a variety of heart failure patients to reduce total mortality.
Cardiac resynchronization therapy should be considered in patients with cardiac dysynchrony (QRS greater than 0.12 ms) who have a left ventricular ejection fraction less than or equal to 35%, are in sinus rhythm, and are in NYHA Class III or IV despite medical therapy.
Addition of an aldosterone antagonist is reasonable in selected patients with moderate to severe symptoms of heart failure and reduced left ventricular ejection fraction.
Treatment with an ARB is a reasonable first line option to use as an alternative to an ACEI for patients with mild to moderate heart failure and reduced left ventricular ejection fraction.
Digitalis can be beneficial to reduce hospitalizations in patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction.
A combination of hydralazine and a nitrate may be reasonable in patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction who can not tolerate an ACEI or ARB
Stage D: Refractory end-stage Heart Failure
Options for end-of-life care should be discussed with the patient and their family once severe symptoms of heart failure persist
Patients with end-stage heart failure and and ICD should receive information about the option to inactivate defibrillation.
Consideration of a left ventricular assist device as permanent or destination therapy is reasonable in patients with refractory heart failure with an estimated 1-year mortality of over 50% despite medical therapy
Download the ACC/AHA Recommendations for Treating CHF Cheat Sheet
Your Download Will Begin Automatically in 5 Seconds.