The American College of Cardiology (ACC) and the American Heart Association (AHA) jointly compose guidelines in the area of cardiovascular disease and update them as understanding of disease processes and treatment strategies evolve. These guidelines are intended to assist health care providers in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, and prevention of specific diseases or conditions.

The guideline reviewed here is a 2005 update¹ to the 2001 guidelines² for the evaluation and management of heart failure (HF). In the 2001 document, the ACC/AHA introduced four stages (A, B, C, and D) in the development of HF (see Table 1).² The first two stages (A and B) identify patients with risk factors that predispose them to developing HF. Stage C includes those patients with current or previous HF and known structural heart disease. Stage D incorporates patients who have refractory HF despite optimal medical care and who may be eligible for advanced or specialized treatments/procedures. The Clinical and Scientific Affairs Council of the AAPA has reviewed the guideline update and summarizes the changes here. 

Relevant population and risk factors

The 2005 guideline update recommendations are directed at the adult population and recognize that any form of heart disease can ultimately lead to HF. Early recognition and proper treatment of cardiovascular risk factors such as hypertension and diabetes may help to delay or prevent the onset of HF. Treatment for special populations, including women, members of minority groups, and the elderly, is also addressed. 

Intent of the guideline update

The 2005 update addresses the following topics: HF as a clinical syndrome, initial and serial clinical assessments, pharmacologic and nonpharmacologic therapies, treatment of special populations, patients with HF and concomitant disorders, end-of-life considerations, and implementation of practice guidelines. The ACC and the AHA jointly utilize a standardized approach to recommending procedures and treatments and to describing the validity of such recommendations. Recommendations are referred to by class (I, IIa, IIb, and III) (see Table 2). For each class, benefits are compared with risks to determine whether a procedure or treatment should be recommended, is probably recommended, may/might be considered, or is not recommended or indicated. Validity is measured by level of evidence (A, B, C) (see Table 3). Each level arises from data derived from multiple randomized trials or meta-analyses, a single randomized trial or nonrandomized studies, consensus opinion, case studies, or standards of care. 

SUMMARY OF CHANGES

New and significant changes to the 2001 document are highlighted below. The reader is encouraged to review the complete document for a more detailed description. 

Initial clinical assessment

Class I indications in the patient history now include screening for behaviors that may cause or accelerate the development or progression of HF as well as screening for use of excessive alcohol, illicit drugs, alternative therapies, and chemotherapy drugs. Measurement of orthostatic BPs and a calculation of body mass index should be added to the physical examination. Laboratory data should include fasting blood glucose and glycohemoglobin levels and a lipid profile. Echocardiography is recommended during the initial evaluation to assess left ventricular ejection fraction (LVEF), size, and valve function. Coronary arteriography should be performed in patients who have angina or significant ischemia.

Class IIa recommendations change the level of evidence for noninvasive imaging in patients with known coronary artery disease (CAD) and no angina. Maximal exercise testing with or without measurement of respiratory gas exchange; screening for sleep-disturbed breathing; HIV testing; diagnostic tests for rheumatologic diseases, amyloidosis, or pheochromocytoma; and endomyocardial biopsy are reasonable and can be useful in selected patients. Measurement of B-type natriuretic peptide can be helpful in the evaluation of patients presenting in the urgent care setting.

Class IIb recommendations now include Holter monitoring in patients who have a history of MI and are being considered for electrophysiologic study. 

Serial clinical assessment

Class I recommendations now include an assessment at each visit of routine and desired activities of daily living, volume status, weight, and a history of current use of alcohol, tobacco, illicit drugs, alternative therapies, and chemotherapy drugs, as well as diet and sodium intake. Class IIa recommendations suggest repeating measurements of LVEF and assessments of the severity of structural remodeling in patients with a change in clinical status. The value of serial measurements of BNP is not well established and receives a class IIb recommendation.