• Heart Failure
• Cardiology Guidelines

• Cardiology & Cardiovascular Medicine
• Heart Failure
• Cardiology Guidelines

A joint symposium of the Heart Failure Society of America (HFSA) and the American College of Cardiology (ACC) was held to discuss the 2013 update to the American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) Guidelines for the management of HF [Yancy CW et al. J Am Coll Cardiol 2013; Circulation 2013]. The symposium began with an introduction by guideline writing committee chair, Clyde W. Yancy MD, MSc, Northwestern University Chicago, Illinois, USA. Harmonization between the 2013 ACCF/AHA Guidelines and the European Society of Cardiology (ESC) Guideline for the diagnosis and treatment of acute and chronic HF [McMurray JJ et al. Eur Heart J 2012] and the HFSA 2010 comprehensive HF practice guideline [Lindenfeld J et al. J Card Fail 2010] were also discussed in the session.

Dr. Yancy briefly discussed aspects of the 2013 ACCF/AHA Guidelines. HF with reduced ejection fraction (HFrEF) has an EF cutoff ≤40%. HeF with preserved ejection fraction (HFpEF) has an EF cutoff ≥50%. HF with EF 41% to 49% is now termed HFpEF-borderline. A new recognition has also been made for patients with improved systolic function (EF increase to >40), termed, HFpEF-improved. In addition, Stage C disease management is now divided into specific medical and device management for both HFpEF and HFrEF. A number of the available risk scores to help clinicians predict outcomes in HF have been added with hyperlinks to the online resources. The role of arginine vasopressin antagonists to treat hypervolemic hyponatremia in hospitalized HF patients is discussed. In addition, emphasis on transitioning care in the hospital and ambulatory settings, coordinating care for HF patients, and optimizing processes to improve care quality have received significant attention.

Pharmacological therapy across the different HF guidelines was reviewed by Randall C. Starling, MD, MPH, Cleveland Clinic, Cleveland, Ohio, USA. Guideline-directed medical therapy (GDMT) is emphasized in the 2013 ACCF/AHA Guideline. For patients with HFrEF, Class I indicated medical therapy includes ACE-inhibitors (ACE-I), angiotensin receptor blockers (if ACE-I intolerant), and β-blockers. For select patients with HFrEF, aldosterone antagonists, hydrazaline-nitrates, anticoagulation, and/or diuretics should be added to the regimen. While the recommendations are largely consistent the latest ACCF/AHA and ESC HF guidelines, Dr. Starling noted that the ESC includes use of ivabradine, a novel rate-lowering drug recommended for specific patients with HFrEF that is not available in the United States.

The 2013 ACCF/AHA Guidelines give aldosterone antagonists a Class I with Level of Evidence (LOE) A recommendation, but with more strict guidelines for appropriate patient selection than the ESC Guidelines. Both guidelines are harmonized regarding the potential for harm when aldosterone antagonists are used inappropriately. Recommendations for hydralazine-isosorbide dinitrate are now harmonized in the 2013 ACCF/AHA and HFSA Guidelines. Regarding HFpEF, a syndrome which remains poorly understood without any evidence-based targeted treatments, Dr. Starling stated “there's definitely a gap of evidence here. This is completely harmonized: all of the guidelines say treat the underlying disease. We don't have the evidence, and that's the state of where things are today.”

W. H. Wilson Tang, MD, Cleveland Clinic, Cleveland, Ohio, USA, gave an overview of device recommendations across the guidelines. The guidelines are largely harmonized with minor discrepancies primarily due to the large amount of new data published since 2010. One of the major developments has occurred in implantable cardioverter-defibrillator (ICD) programming. A great deal has been learned regarding device management, particularly in delaying the needed response for shock as learned in the Multicenter Automatic Defibrillator Implantation Trial-Reduce Inappropriate Therapy [MADIT-RIT; Moss AJ et al. N Engl J Med 2012].

Other notable changes in the guidelines have occurred in cardiac resynchronization therapy (CRT). The benefit of CRT across the spectrum of symptomatic HF is now well established. One of the major changes to the ACCF/AHA Guidelines for CRT is that the Class I indication is limited to patients with EF ≤35%, sinus rhythm, QRS duration ≥150 ms and left bundle branch block (LBBB) and NYHA II, III, or ambulatory IV. Class IIa indications expand the use of CRT to those with non-LBBB patterns and QRS duration of 120 to 149 ms. “The evolution of the CRT indication really is a refinement of what we knew a few years. Clearly the emphasis now is longer QRS duration and LBBB morphology,” summarized Dr. Tang. A recent comprehensive expert consensus statement from the Heart Rhythm Society provides further description regarding use of this technology including maximization of pacing, synchronization optimization, rhythm management, end-of-life considerations, device diagnostics, and remote monitoring.

Biykem Bozkurt, MD, PhD, Baylor College of Medicine, Houston, Texas, USA, compared how the guidelines differ in regard to adjunct therapies, for example sodium restriction and fluid restriction. A comparison of the HFSA, ACCF/AHA, and ESC guidelines regarding adjunctive therapies is presented in Table 1. In general, recommendations across these guidelines are more consistent when based on large well-conducted studies. “There are quite a few gaps in knowledge about the benefit of adjunct therapies that need further study with randomized controlled trials or high-quality observational studies, systematic reviews, or meta-analyses, especially in the areas of salt restriction, treatment of sleep disordered breathing weight loss in obesity, and percutaneous and other interventional approaches,” concluded Dr. Bozkurt.

Gregg C. Fonarow, MD, University of California, Los Angeles, Los Angeles, California, USA, concluded the symposium by addressing the beneficial impact of guideline adherence and highlighting questions requiring additional research, so called “evidence gaps”, that will need to be addressed in future guidelines (Table 2). Although unanswered questions remain, treatment strategies that follow the HF guidelines translate into better patient outcomes. Using the 2005 ACCF/AHA Guidelines for the diagnosis and management of chronic HF in adults [Hunt SA et al. J Am Coll Cardiol 2005; Hunt SA et al. Circulation 2005] and the 2009 Focused Update [Hunt SA et al. J Am Coll Cardiol 2009; Circulation 2009], each 10% improvement in composite care adherence of HF outpatients lowered the odds of 2-year mortality by 13% (adjusted OR, 0.87; 95% CI, 0.84 to 0.90; p<0.0001) [Fonarow GC et al. Circulation 2011]. “This gives us the impetus to further refine and improve our guidelines as our evidence base expands because its application in practice does indeed improve clinical outcomes,” said Dr. Fonarow.

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