Heart failure (HF) is the No. 1 cause of both hospitalization and readmission among Americans 65 years and older.1 Hospitalizations in the HF population are associated with poor patient outcomes (30% mortality in the following year) and high costs, accounting for approximately 70% of the $32 billion spent on HF care annually in the United States.1 In 2009, the Centers for Medicare & Medicaid Services (CMS) introduced the 30-day, risk-standardized, all-cause readmission for HF as an indicator of quality and efficiency of care, which has since been incorporated into Medicare’s value-based purchasing program.2
HF is a complex syndrome that is associated with multiple comorbidities. Appropriate to these issues, management is multifaceted and involves care across the spectrum of disease:
- Diagnosing and treating underlying causes;
- Minimizing exacerbants;
- Optimizing management of comorbidities;
- Addressing psychosocial and environmental issues beyond the hospital; and
- Confronting end-of-life care.
In order to address this continuum of disease management, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) simultaneously released a new Guideline for the Management of HF in June in the Journal of the American College of Cardiology and Circulation.3,4 This update was developed in collaboration with the American Academy of Family Physicians, American College of Chest Physicians, Heart Rhythm Society, and the International Society for Heart and Lung Transplantation. The goals of the document are to improve quality of care, optimize patient outcomes, and advance the efficient use of healthcare resources. The guideline includes important recommendations for overall care, but particularly for hospital-based care and transitions of care that are largely the purview of hospitalists.
The 2013 guideline is the third revision of the original guideline that was released in 2000. Despite being a complete rewrite of the 2009 HF guideline, the updated document contains relatively few changes to the recommendations that are Class I (should be performed) and III (no benefit or harm). The most significant randomized controlled trials in HF patients that have been published since the 2009 guideline include EMPHASIS-HF5 and MADIT-CRT/RAFT, which expand indications for aldosterone antagonists (AA) and cardiac resyncronization therapy (CRT), respectively, to patients with mild symptoms.5,6,7 Additionally, the WARCEF trial was published, which failed to demonstrate a significant difference in death, ischemic stroke, or intracerebral hemorrhage between treatment with warfarin or aspirin in patients with HF and reduced left ventricular ejection fraction (LVEF) in sinus rhythm.8
The most notable updates from the 2009 guideline include (* = Class I and III indications):
- The definition of HF has been revised to include: 1) HF with reduced ejection fraction (HFrEF; LVEF ≤40%), 2) HF failure with preserved ejection fraction (HFpEF; LVEF ≥50%), 3) HFpEF, borderline (LVEF 41-49%), and 4) HFpEF, improved (LVEF >40%).
- In the hospitalized patient, measurement of brain natriuretic peptide (BNP) or NT-proBNP is useful to support clinical judgment for the diagnosis of acutely decompensated HF, especially in the setting of uncertainty for the diagnosis.*
- AA should be used in patients with New York Heart Association (NYHA) functional Class II-IV and LVEF ≤35% unless contraindicated (creatinine ≤2.5 mg/dL in men, ≤2.0 mg/dL in women, and potassium <5.0 mEq/L).*
- CRT is indicated for patients who have LVEF of 35% or less, sinus rhythm, left bundle-branch block with a QRS duration of ³150 ms, and NYHA functional Class II-IV on guideline-directed medical therapy (GDMT).*
- Anticoagulation should not be used in patients with chronic HFrEF without atrial fibrillation, prior thromboembolic event, or cardioembolic source.*
- Transitions of care and GDMT can be improved by employing the following: 1) use of performance-improvement systems to identify HF patients, 2) development of multidisciplinary HF disease-management programs for patients at high risk of readmission, and 3) placing phone calls to the patient within three days of discharge and scheduling a follow-up visit within seven to 14 days.
Overall, the new guideline provides a thorough reassessment and expert analysis on the diagnosis and management of HF for both inpatient and outpatient care. The authors introduce the phrase “guideline-directed medical therapy” (GDMT) to emphasize the smaller set of recommendations that constitute optimal medical therapy for HF patients. This designation, encompassing primarily Class I recommendations, helps providers rapidly determine the optimal treatment course for an individual patient. The mainstay of GDMT in HFrEF patients remains angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB) when ACE-I-intolerant, beta-blockers, and, in select patients, AA, hydralazine-nitrates, and diuretics.
A major shift in focus is seen in the new guideline with a greater emphasis on improved patient-centered outcomes across the spectrum of the disease. HF requires a continuum of care, from screening and genetic testing of family members of patients with idiopathic cardiomyopathy to conversations about palliative care and hospice. To this end, the authors highlight quality of life, shared decision-making, care coordination, transitions of care, and appropriateness of palliative care in a chronic disease state.
Further, the guideline expands upon previous recommendations for compliance with performance and quality metrics. Quality of care and adherence to performance measures of HF patients are becoming increasingly recognized, particularly in the hospital setting. The guideline offers recommendations for transitions of care in the hospitalized patient, which utilize systems of care coordination to ensure an evidence-based plan of care that includes the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up, and appropriate dietary and physical activities.
HF is one of the most common, most challenging diseases managed by hospitalists. The 2013 ACCF/AHA Guideline for the Management of HF, while providing a comprehensive summary of evidence with recommendations for the totality of care for these patients throughout the course of the disease, places heavy emphasis on management during hospitalization and transitions. This includes repositioning of performance measures involving GDMT to better ensure optimal use of proven therapies in HFrEF, evidence-based steps to reduce readmissions, and greater recognition of the role of palliative care for patients with advanced disease.
Drs. McIlvennan and Allen are cardiologists in the Department of Medicine at the University of Colorado School of Medicine in Denver. Dr. Allen also works in the Colorado Health Outcomes Program.
References available at the-hospitalist.org.