|
 If you prefer to view this article in PDF form, click here.
ACC/AHA 2005 guideline update:
Chronic heart failure in the adult
Lyle W. Larson, PhD, PA-C; Deborah A. Gerbert, PA-C; Lawrence M. Herman, MPA, PA-C; Marie-Michèle Léger, MPH, PA-C; Robert McNellis, MPH, PA-C; Daniel L. O'Donoghue, PhD, PA-C; Cynthia Ulshafer, PA-C; Eileen M. Van Dyke, MPS, PA-C
The authors are members and staff of the Clinical and Scientific Affairs Council (CSAC) of the AAPA. This article was written by Lyle W. Larson, PhD, PA-C, and edited by Sarah Zarbock, PA-C.
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.
Patients who are at high risk for developing HF (Stage A)
Changes to class I recommendations include treating lipid disorders, controlling blood glucose levels, and counseling patients to avoid behaviors that may increase the risk of HF. The ventricular rate should be controlled or sinus rhythm restored in patients with supraventricular tachyarrhythmias; thyroid disorders should be treated; and patients with known atherosclerotic vascular disease should follow current guidelines for secondary prevention. Noninvasive evaluation of left ventricular (LV) function (ie, measuring LVEF) should be performed in patients with a strong family history of cardiomyopathy and in those receiving cardiotoxic interventions.
Class IIa changes state that ACE inhibitors and angiotensin-receptor blockers (ARBs) can be useful in patients with a history of atherosclerotic vascular disease, diabetes mellitus, or hypertension with associated cardiovascular risk factors.
Patients with cardiac structural abnormalities or remodeling but no HF (Stage B)
Class I recommendations include prescribing beta-blockers and ACE inhibitors for all patients with a recent or remote history of MI. These agents may also be used for all patients without a history of MI who have a reduced LVEF with no symptoms of HF. ARBs should be administered to post-MI patients who are intolerant of ACE inhibitors and who have a low LVEF. After an acute MI, patients without symptoms of HF should be treated according to guidelines, including coronary revascularization when appropriate. Valve replacement or repair is recommended for patients with hemodynamically significant valvular stenosis or regurgitation and no symptoms of HF.
Class IIa changes state that ACE inhibitors or ARBs can be beneficial in patients with hypertension and left ventricular hypertrophy (LVH) but no symptoms of HF. ARBs may be beneficial in patients intolerant of ACE inhibitors. Placement of an implantable cardioverter-defibrillator (ICD) is reasonable in patients with ischemic cardiomyopathy and criteria as outlined within the guidelines.
Class IIb recommendations say that placement of an ICD may be considered in patients without HF who have nonischemic cardiomyopathy and an LVEF of 30% or less.
Class III changes advise that digoxin should not be used in patients with a low LVEF, sinus rhythm, and no history of HF symptoms and that calcium channel blockers may be harmful in patients with a low LVEF and no HF symptoms after either a distant or a recent MI.
Patients with reduced LVEF (Stage C)
Class I recommendations add salt restriction to use of diuretics in patients with a reduced LVEF and evidence of fluid retention. ARBs are approved for the treatment of HF in patients who are ACE inhibitor-intolerant, and an aldosterone antagonist may be used in selected patients with severe symptoms of HF and reduced LVEF who can be carefully monitored. Exercise training is added as an adjunctive approach to improve clinical status in ambulatory patients. An ICD is indicated to prolong survival in patients with a history of cardiac arrest or hemodynamically unstable ventricular tachycardia (secondary prevention) and to reduce total mortality in patients with ischemic heart disease or nonischemic cardiomyopathy with an LVEF of 30% or less and criteria as outlined within the guidelines (primary prevention). Patients with an LVEF of 35% or less, sinus rhythm, New York Heart Association (NYHA) functional class III or ambulatory class IV symptoms despite optimal medical therapy, and cardiac dyssynchrony (QRS duration greater than 0.12 msec) should receive cardiac resynchronization therapy. (The NYHA classification system [class I to class IV] is
a functional measure of symptoms and physical activity for patients with HF. Class I patients suffer no symptoms from ordinary activities, while class IV patients suffer symptoms at rest without any physical activity.)
Class IIa changes affirm that ARBs are alternatives to ACE inhibitors as first-line therapy for patients with mild to moderate HF and reduced LVEF and that digoxin may be beneficial in patients with current or prior symptoms of HF and reduced LVEF. A combination of hydralazine and a nitrate is reasonable for patients with persistent symptoms and reduced LVEF who are already taking an ACE inhibitor and a beta-blocker.
Class IIb changes suggest that the combination of hydralazine and a nitrate may be reasonable when ACE inhibitors or ARBs are contraindicated because of drug intolerance, hypotension, or renal insufficiency.
Class III changes recommend against the routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist and against the use of calcium channel blocking drugs for routine treatment for HF.
Patients with end-stage HF (Stage D)
Class I recommendations add discussing options for end-of-life care with the patient and family when severe symptoms in refractory end-stage HF persist despite use of all recommended therapies. Discussion should cover inactivating the ventricular fibrillation detection algorithm for ICDs if appropriate.
Class IIa additions endorse consideration of an LV assist device as permanent or “destination” therapy in highly selected patients with refractory end-stage HF and an estimated 1-year mortality higher than 50% with medical therapy.
Treatment of special populations
Class I indications for treatment of special populations encompass high-risk ethnic groups (eg, blacks), groups underrepresented in clinical trials, and any groups believed to be underserved. All groups should have clinical screening and therapy in a manner identical to that applied to the broader population. It is also recommended that evidence-based therapy for HF be used in the elderly patient as is appropriate.
Class IIa recommendations support the idea that the addition of isosorbide dinitrate and hydralazine to a standard medical regimen of ACE inhibitors and beta-blockers can be effective in blacks with NYHA functional class III or IV HF.
Patients with HF who have concomitant
disorders
Class I changes recommend that all reasonable treatment modalities should apply to patients with concomitant disorders unless there are specific exceptions. Antiplatelet agents should be prescribed for prevention of MI and death in patients with HF and underlying CAD.
Class IIa changes indicate that it is reasonable to prescribe amiodarone to decrease recurrence of atrial arrhythmias and prevent or decrease ICD discharges.
Class III changes argue against the use of antiarrhythmic agents as primary treatment for asymptomatic ventricular arrhythmias.
End-of-life considerations
Class I changes recommend educating the patient and family regarding the role of palliative care and hospice services, discussing the option of inactivating ICDs, and not precluding the use of inotropes and intravenous diuretics for symptom palliation.
Implementation of practice guidelines
Class I additions suggest multidisciplinary disease-management programs to attack barriers to behavioral change and to reduce the risk of subsequent hospitalization for patients at high risk.
Class IIa changes support the use of performance measures based on practice guidelines to improve quality of care.
The take-home message for PAs
Many of the changes in the ACC/AHA 2005 guideline update stress the need for early diagnosis and treatment for patients with HF. The salient points include these:
• HF is a clinical diagnosis based on specific symptoms in the medical history and specific signs on the physical examination. No single diagnostic test exists.
• Any form of heart disease may lead to HF. Noncardiac causes of HF should be considered in the differential diagnosis.
• Not all patients with HF have volume overload at the time of initial or subsequent evaluation.
• Early recognition and proper treatment of cardiovascular risk factors are important to prevent HF or slow its progression.
• One of the main symptoms of HF is fatigue. Dyspnea, fatigue, and fluid retention can occur independently of each other.
• Congestive HF is now called simply HF. The term congestive was eliminated because patients can have few symptoms of congestion and still have a severely abnormal heart with symptoms of fatigue and exercise intolerance due to poor cardiac output.
• Patients with a normal LVEF can have diastolic HF (in which the heart pumps properly but fails to fill with blood).
• The ACC/AHA classification system is meant to complement but not replace the NYHA classification system. Stages A and B are asymptomatic but should be treated nonetheless. The treatment for patients at each stage of HF should incorporate the treatments used for patients in prior stages.
• Limitations of the NYHA classification system exist because most patients do not show uninterrupted and inevitable worsening of symptoms. The severity of symptoms fluctuates even in the absence of medication changes, and changes in medications and diet can have favorable or adverse effects on functional capacity in the absence of any measurable change in ventricular function.
• HF does not go away. Patients with HF need regular medical care.
• Left ventricular assist devices may be considered as permanent or “destination therapy” in selected patients with HF.
• The number of patients who are eligible to receive ICDs should be expanded.
• HF is often fatal even though advances in treatment can prolong life as well as improve its quality. Practitioners should be willing to provide information on end-of-life issues.
REFERENCES
1. ACC/AHA Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult. J Am Coll Cardiol. 2005;46:1116-1143.
2. Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol. 2001;38:2101-2113.
| 
