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| TITLE |
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ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). Developed in Collaboration With the American College of Chest Physicians and the International Society for Heart and Lung Transplantation. Endorsed by the Heart Rhythm Society
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| AUTHORS |
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Sharon A Hunt, William T. Abraham, Marshall H Chin, Arthur M Feldman, Gary Francis, Theodore G Ganiats, Mariell Jessup, Marvin A Konstam, Donna M Mancini, Keith Michl, John A Oates, Peter S Rahko, Marc A Silver, Lynne W. Stevenson, Clyde W Yancy, Elliott M Antman, Sidney C Smith, Cynthia D Adams, Jeffrey L Anderson, David P Faxon, Valentin Fuster, Jonathan L Halperin, Loren F Hiratzka, Alice K Jacobs, Rick A. Nishimura, Joseph P Ornato
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| PUBLICATION INFORMATION |
Journal Name: Circulation
Volume: 112
Pages: e154-235
Date Published: 09/20/2005
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| ABSTRACT/REVIEW |
Introduction
The American College of Cardiology (ACC) and the American Heart Association (AHA) issued new guidelines on Sept. 20, 2005 to help cardiologists diagnose and treat heart failure based on a consensus of experts who reviewed the latest findings of current research. These practice guidelines are intended to assist healthcare providers in clinical decision-making by describing a range of generally acceptable approaches for the prevention, diagnosis, and management of heart failure.
The full 82-page guideline document is available on the Websites of the ACC (www.acc.org) and the AHA (www.americanheart.org), and was published in the Sept. 20, 2005 issues of the Journal of the American College of Cardiology and Circulation: Journal of the American Heart Association.
The following highlights some of the significant changes to the previous guidelines published in 2001. The committee elected to focus on the prevention of heart failure and on the diagnosis and management of chronic heart failure in the adult patient with normal or low left ventricular ejection fraction. Normally, with each heart beat, the heart pumps the majority of the volume of blood that has filled the lower left heart chamber (left ventricle) out to the rest of the body. The ejection fraction is low if the heart is unable to pump the proper volume out of the ventricles.
This guideline update also excludes heart failure (HF) in children, both because the underlying causes of HF in children differ from those in adults and because none of the controlled trials of treatments for HF analyzed by the committee included children.
Background
From 1990-99, the number of people hospitalized with a primary diagnosis of heart failure increased from 810,000 to more than 1 million. This was due to the aging population and to more people surviving heart attacks. Heart failure mostly affects the elderly, and more Medicare dollars are spent for heart failure diagnosis and treatment than for any other disease. About 5 million U.S. residents are living with heart failure, and more than 550,000 people are diagnosed with the condition each year. In 2005, the disease will cost an estimated $27.9 billion in direct and indirect health care expenses.
Summary of major changes
Looking at the broad spectrum of findings in cardiovascular clinical research, the consensus committee recognized that research findings have changed the way cardiologists now think about and approach the diagnosis and treatment of heart disease as it relates to heart failure. For that reason they both changed the name of the condition and changed the way it is defined.
Formerly the guidelines called the condition congestive heart failure. The new guidelines changed the name to heart failure (HF) in an effort to shift the emphasis to early detection and early treatment. According to the new heart failure guidelines released by the two groups, it is hoped the new name will more accurately reflect the full spectrum of the disease.
Congestion occurs when fluid builds up in the lungs because the heart cannot efficiently pump or eject blood from its chambers. This results in stiff, fluid-filled lungs and shortness of breath.
The panel dropped the word "congestive" because people can have few or no symptoms of congestion, and still have a severely abnormal heart with symptoms of fatigue and exercise intolerance caused by the heart's inability to pump enough blood to supply the needs of the body.
Consequently, the committee redefined heart failure as a complex clinical condition that can result from any structural or functional cardiac disorder that interferes with the ability of the ventricles to fill with or eject blood. Common symptoms of HF are shortness of breath (dyspnea) and fatigue, which may limit exercise tolerance, and increased fluid retention, which may lead to fluid buildup in the lungs (pulmonary congestion) and body (peripheral edema).
The earliest indication of heart failure, say the guidelines, is a change in the shape or structure of the heart. This is followed by symptoms of fatigue and shortness of breath associated with moderate exercise.
While ejection fraction is used as a primary measure of heart failure, the committee also recognized that, in recent years, doctors have found that many people with normal ejection fractions have heart failure. In some forms of heart failure the heart pumps properly, but fails to fill adequately with blood, a condition called diastolic heart failure. Patients who have diastolic heart failure rarely have been included in clinical trials of new drugs and devices, but they are the subjects of several new, ongoing trials. These trials should help settle the issue of whether their treatment should be the same as that for patients with reduced ejection fraction.
Another major emphasis of the updated guidelines is based on the research showing that nearly any form of heart disease may ultimately lead to heart failure. Consequently, these guidelines stress that early recognition and proper treatment of high blood pressure, diabetes, coronary artery disease, and other cardiovascular risk factors can help patients delay or avoid heart failure. There is no single diagnostic test for HF because it is largely a clinical diagnosis that is based on a careful history and physical examination.
The key to prevention is to get the risk factors under control. For instance, studies have shown that controlling high blood pressure (hypertension) can reduce the incidence of heart failure by 50%.
Noting that heart failure is a progressive yet potentially preventable disease, and that symptoms may fluctuate and don't always correlate with the degree of structural and functional changes of the heart, the authors recommended staging heart failure based on the progression from risk factors alone to end-stage disease:
- Stages A and B represent patients who lack early signs or symptoms of heart failure, but are at risk because of risk factors or heart abnormalities, which could include a change in the shape or structure of the heart.
- Stage C denotes patients who have changes in the shape or structure of their hearts with current or past heart failure symptoms such as shortness of breath.
- Stage D designates patients who have advanced heart failure that is difficult to manage with standard treatment. These patients might be eligible for specialized advanced treatment — including cardiac transplantation — or compassionate end-of-life care such as hospice.
Typically Stage A patients have high blood pressure, high cholesterol or other lipid abnormalities, coronary artery disease, or diabetes. These risk factors should be treated. Additionally, physicians should encourage exercise, discourage alcohol and/or drug abuse, and target metabolic syndrome in these patients.
Stage B should be treated in the same way as stage A patients, but the use of an ACE inhibitor or an angiotensin receptor blocker (ARB) should be considered as well. Moreover, beta-blockers should be initiated in appropriate patients.
Stage C patients should be managed following the recommendations for stage A and B, but diuretics, ACE inhibitors and beta-blockers should be part of routine management. Aldosterone antagonists, ARBs, digitalis, and hydralazine/nitrates should also be initiated in selected patients. Selected stage C patients should also be considered for biventricular pacing devices, implantable defibrillators, or both.
Evaluation changes
The committee made numerous changes to the way doctors assess patients for heart failure. They made changes to recommendations regarding the initial evaluation, and identification of structural and functional abnormality, history and physical examinations, laboratory testing, evaluation of coronary artery disease, and assessment of prognosis.
These changes include greater emphasis on patient history inquiring in more detail regarding:
- High blood pressure (hypertension)
- Diabetes mellitus
- Cholesterol or other lipid abnormalities (dyslipidemia)
- Valvular heart disease
- Coronary artery disease
- Peripheral vascular disease
- Diseases of the muscles (myopathy)
- Rheumatic fever
- Middle chest (mediastinal) irradiation (such as may be given for cancer)
- History or symptoms of sleep-disordered breathing
- Exposure to agents that are damaging to the heart (cardiotoxic), such as some stimulants and some cancer medications
- Current and past alcohol consumption
- Smoking
- Collagen vascular disease
- Exposure to sexually transmitted diseases
- Thyroid disorders
- Pheochromocytoma (a type of tumor of the adrenal gland)
- Obesity
Also greater attention should be paid to family history such as:
- Atherosclerotic disease (as evidenced by history of heart attacks, strokes, or peripheral vascular disease)
- Sudden cardiac death
- Diseases of the smooth (involuntary) muscles
- Conduction system disease (which may require a pacemaker)
- Tachyarrhythmias (abnormal fast heart rhythms)
- Unexplained cardiomyopathy
- Diseases of the skeletal (voluntary) muscles
Treatment recommendations
A second major point of the updated guidelines is that heart failure does not go away. There are drugs that need to be used and medical care that needs to be provided on a regular basis.
The committee recognized that, in recent years, more available treatments have made decision-making far more complex since the last ACC/AHA heart failure guidelines four years ago. They made numerous adjustments to previous treatment recommendations for each of the stages outlined above. There are too many to be summarized here. Below highlights a few of the more substantial changes to treatment. The committee made these recommendations:
Drug treatment
- The guidelines recommend that after heart attack, patients should take aspirin daily and receive beta-blockers.
- They also strongly endorsed the use of angiotensin converting enzyme (ACE) inhibitors to improve heart function for all patients who have heart failure or are at high risk for developing heart failure.
- For those patients who cannot tolerate an ACE inhibitor, the guidelines suggest an angiotensin receptor blocker (ARB). For those who cannot tolerate either ACE inhibitors or ARBs, the combination of hydralazine and isosorbide dinitrate may be a reasonable alternative.
- Beta-blockers, particularly bisoprolol, carvedilol, and sustained release metoprolol succinate, are recommended for patients who have low ejection fractions and either current or past heart failure symptoms.
- An ARB may be prescribed to patients who have low ejection fractions and remain symptomatic despite conventional therapy.
- A combination of hydralazine and a nitrate may be prescribed to patients who have low ejection fractions and remain symptomatic despite conventional therapy.
- The combination of isosorbide dinitrate and hydralazine can be effective in African Americans with NYHA functional class III or IV when added to conventional therapy.
- Aldosterone antagonists may be helpful for patients who have low ejection fractions and moderately severe to severe symptoms. Kidney functions and potassium levels must be monitored during therapy.
- Using the triple combination of an ACE inhibitor, an ARB, and an aldosterone antagonist is not recommended.
- Digoxin can help to reduce hospitalizations in patients who have heart failure with either current or past symptoms; however, it should not be used in patients who have never had symptoms.
- The recommendation for exercise to improve health for patients who are able to walk about was added.
Medical devices
- Left ventricular assist devices (LVADs) should be considered as permanent or "destination" therapy in selected patients. LVADs are implanted mechanical devices that help pump blood through the heart and can be used as a reasonable permanent therapy in some end-stage heart failure patients who are not candidates for transplants, don't respond to standard treatment, and have a one-year survival outlook of less than 50%. The devices, which recently received U.S. Food and Drug Administration approval as permanent or "destination" therapy, were first used as a temporary measure to keep patients alive while waiting for a heart transplant.
- Expand the number of patients eligible for implantable cardioverter-defibrillators (ICDs), devices implanted under the skin that save lives by shocking chaotic heart rhythms back into a healthy pattern.
Hospice care
- Provide information on end-of-life issues. Although treatment advances can extend lives, heart failure is often fatal. The guidelines recommend that cardiologists broach the subject of hospice care — support and comfort for dying patients and their families.
The committee noted that in the past doctors have failed to adequately recognize that end-stage heart failure patients frequently come in and out of the hospital over and over again and suffer a lot with really no impact on their ultimate survival. Hospice is a way of improving the remaining days that these patients have. Hospice can be a very positive experience for patients and their families. Cardiologists aren't used to talking about hospice. They are more used to doing interventions. This represents a new role for many cardiologists. The guidelines also suggest that a new perspective on treating end-stage heart failure could result in a smoother, less stressful transition for patients and their families.
Overall, the new 2005 guidelines for heart failure changes the definition and evaluation of heart failure and places greater emphasis on recognizing heart failure as a progressive disease that can be slowed or halted by early treatment of high blood pressure, diabetes, coronary artery disease, and other cardiovascular risk factors.
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