In the Journals

ACC, AHA, HFSA release updated guidelines for HF management

Updated guidelines for HF management from the American College of Cardiology, American Heart Association and the Heart Failure Society of America include the first recommended therapy for patients with HF with preserved ejection fraction.

The guidelines also include for the first time a section on hypertension.

“For clinical practice guidelines to be truly useful, new evidence that changes clinical practice should be rapidly incorporated in the guidelines and disseminated to the practice community,” Clyde W. Yancy, MD, MSc, MACC, FAHA, FHFSA, chair of the writing group for the guidelines and vice dean for diversity and inclusion, chief of cardiology in the department of medicine and professor of medicine and medical social sciences at Northwestern University Feinberg School of Medicine, said in a press release. “These updates were deemed necessary as new evidence in all of the areas addressed, derived from clinical trials, has emerged since the 2013 Heart Failure Guidelines and now merits inclusion.”

The panel wrote that aldosterone receptor antagonists may be reasonable in selected patients with HFpEF to reduce hospitalizations. Regular use of phosphodiesterase-5 inhibitors or nitrates is not recommended for patients with HFpEF to increase their quality of life, as it is ineffective.

Clyde W.Yancy, MD, MSc
Clyde W. Yancy

“For the first time, we have endorsed, softly, a new treatment recommendation for HFpEF,” Yancy told Cardiology Today. “Given the burden of this condition, it was imperative that we bring the newest data forward.”

Biomarker screening

Guidelines regarding biomarkers for the prevention, diagnosis and prognosis of HF were updated to reflect new data. Natriuretic peptide biomarker-based screenings and subsequent team-based care are reasonable for the prevention of new-onset HF or left ventricular dysfunction in patients who are at risk for developing HF. Measurement of biomarkers are also recommended to confirm the exclusion or diagnosis of HF in patients with labored breathing.

Physicians should measure B-type natriuretic peptide or N-terminal pro–B-type natriuretic peptide to determine disease severity and prognosis of patients with chronic HF, Yancy and colleagues wrote. In patients with acutely decompensated HF who are admitted to the hospital, physicians should measure baseline levels of cardiac troponin and/or natriuretic peptide biomarkers to determine prognosis. It is recommended that physicians measure natriuretic peptide levels in patients who are hospitalized before discharge to establish postdischarge prognosis. Results from other clinically available tests may be reasonable to determine additional risk in patients with chronic HF.

Erythropoietin-stimulating agents are not useful in patients with HF and anemia to improve mortality and morbidity, the authors wrote.

Hypertension recommendations

A new section on patients with hypertension recommends that the ideal BP in patients with an increased risk for stage A HF is less than 130/80 mm Hg. Those with HF with reduced ejection fraction and hypertension are recommended to take guideline-determined medical therapy titrated to achieve the optimal systolic BP.

Once volume overload is managed, patients with HFpEF and hypertension are recommended to be prescribed guideline-determined medical therapy titrated to achieve an ideal systolic BP less than 130 mm Hg.

“The prevention data regarding treatment of hypertension to prevent [HF] should be the biggest take-home message,” Yancy said to Cardiology Today. “Even after just the first symptom, outcomes in HF are greatly challenged. Let’s keep patients out of the [HF] club. Despite great therapies, outcomes are still too worrisome. It is better to prevent this disease than to have to treat it.”

A formal sleep assessment can be useful for patients with NYHA class II to IV HF who may have excessive daytime sleepiness or sleep-disordered breathing. Continuous positive airway pressure may be considered for those with CVD who have been diagnosed with obstructive sleep apnea to enhance daytime sleepiness and sleep quality. Adaptive servo-ventilation is potentially harmful for patients with NYHA class II to IV HFrEF, according to the authors.

The update does not address areas for which there is insufficient evidence, Yancy told Cardiology Today.

“Many in the community have already asked us about device therapy, [HF] with improved [ejection fraction], genomics, etc,” he said. “We share the strong curiosity expressed by our colleagues, but evidence needs to direct guidelines, not the other way around.” – by Darlene Dobkowski

Disclosure : Yancy reports no relevant financial disclosures. Please see the full guidelines for the other authors’ relevant financial disclosures.

Updated guidelines for HF management from the American College of Cardiology, American Heart Association and the Heart Failure Society of America include the first recommended therapy for patients with HF with preserved ejection fraction.

The guidelines also include for the first time a section on hypertension.

“For clinical practice guidelines to be truly useful, new evidence that changes clinical practice should be rapidly incorporated in the guidelines and disseminated to the practice community,” Clyde W. Yancy, MD, MSc, MACC, FAHA, FHFSA, chair of the writing group for the guidelines and vice dean for diversity and inclusion, chief of cardiology in the department of medicine and professor of medicine and medical social sciences at Northwestern University Feinberg School of Medicine, said in a press release. “These updates were deemed necessary as new evidence in all of the areas addressed, derived from clinical trials, has emerged since the 2013 Heart Failure Guidelines and now merits inclusion.”

The panel wrote that aldosterone receptor antagonists may be reasonable in selected patients with HFpEF to reduce hospitalizations. Regular use of phosphodiesterase-5 inhibitors or nitrates is not recommended for patients with HFpEF to increase their quality of life, as it is ineffective.

Clyde W.Yancy, MD, MSc
Clyde W. Yancy

“For the first time, we have endorsed, softly, a new treatment recommendation for HFpEF,” Yancy told Cardiology Today. “Given the burden of this condition, it was imperative that we bring the newest data forward.”

Biomarker screening

Guidelines regarding biomarkers for the prevention, diagnosis and prognosis of HF were updated to reflect new data. Natriuretic peptide biomarker-based screenings and subsequent team-based care are reasonable for the prevention of new-onset HF or left ventricular dysfunction in patients who are at risk for developing HF. Measurement of biomarkers are also recommended to confirm the exclusion or diagnosis of HF in patients with labored breathing.

Physicians should measure B-type natriuretic peptide or N-terminal pro–B-type natriuretic peptide to determine disease severity and prognosis of patients with chronic HF, Yancy and colleagues wrote. In patients with acutely decompensated HF who are admitted to the hospital, physicians should measure baseline levels of cardiac troponin and/or natriuretic peptide biomarkers to determine prognosis. It is recommended that physicians measure natriuretic peptide levels in patients who are hospitalized before discharge to establish postdischarge prognosis. Results from other clinically available tests may be reasonable to determine additional risk in patients with chronic HF.

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Erythropoietin-stimulating agents are not useful in patients with HF and anemia to improve mortality and morbidity, the authors wrote.

Hypertension recommendations

A new section on patients with hypertension recommends that the ideal BP in patients with an increased risk for stage A HF is less than 130/80 mm Hg. Those with HF with reduced ejection fraction and hypertension are recommended to take guideline-determined medical therapy titrated to achieve the optimal systolic BP.

Once volume overload is managed, patients with HFpEF and hypertension are recommended to be prescribed guideline-determined medical therapy titrated to achieve an ideal systolic BP less than 130 mm Hg.

“The prevention data regarding treatment of hypertension to prevent [HF] should be the biggest take-home message,” Yancy said to Cardiology Today. “Even after just the first symptom, outcomes in HF are greatly challenged. Let’s keep patients out of the [HF] club. Despite great therapies, outcomes are still too worrisome. It is better to prevent this disease than to have to treat it.”

A formal sleep assessment can be useful for patients with NYHA class II to IV HF who may have excessive daytime sleepiness or sleep-disordered breathing. Continuous positive airway pressure may be considered for those with CVD who have been diagnosed with obstructive sleep apnea to enhance daytime sleepiness and sleep quality. Adaptive servo-ventilation is potentially harmful for patients with NYHA class II to IV HFrEF, according to the authors.

The update does not address areas for which there is insufficient evidence, Yancy told Cardiology Today.

“Many in the community have already asked us about device therapy, [HF] with improved [ejection fraction], genomics, etc,” he said. “We share the strong curiosity expressed by our colleagues, but evidence needs to direct guidelines, not the other way around.” – by Darlene Dobkowski

Disclosure : Yancy reports no relevant financial disclosures. Please see the full guidelines for the other authors’ relevant financial disclosures.