Clinical question: What guidance is there for clinical care of complex heart failure patients?
Background: The prevalence of heart failure (HF)is escalating and consumes significant health care resources, inflicts significant morbidity and mortality, and greatly affects quality of life. There is a plethora of research, multiple medical therapies, devices, and care strategies that have been shown to improve outcomes in heart failure patients. Previous publications have reviewed evidence-based literature but left a gap in knowledge for those more-complex areas or lacked practical clinical guidance. This policy document was created to guide physicians in informed decision making in a directed decision pathway form.
Study design: Expert consensus guidelines.
Setting: American College of Cardiology Task Force on Expert Consensus Decision Pathways.
Synopsis: A multidisciplinary group of specialties including physicians, nurses, pharmacists, epidemiologists, and patient advocacy groups addressed 10 pivotal issues in heart failure through literature review, expert consensus, and round table discussion.
Ten principles were identified and addressed:
- Initiating, adding, or switching to new evidenced-based guideline-directed therapy.
- Achieving optimal therapy using multiple HF drugs and therapies.
- Knowing when to refer a patient to an HF specialist.
- Addressing the challenges of care coordination for team-based HF treatment.
- Improving patient adherence.
- Managing specific patient cohorts, such as African Americans, older adults, and the frail.
- Managing your patients’ cost of care for HF.
- Reducing costs and managing the increased complexity of HF.
- Managing the most common cardiac and noncardiac comorbidities.
- Integrating palliative care and transitioning patients to hospice care
Bottom line: Structured guidelines to provide practical and actionable recommendations to improve heart failure outcomes, integrate evidence-based medicine when available, and utilize expert conscious when evidence-based medicine is not available.
Citation: Yancy CW et al. 2017 ACC expert consensus on decision pathway for optimizing of heart failure treatment: Answers to 10 pivotal issues about heart failure with reduced ejection fraction. J Am Coll Cardiol. 2018 Jan 16;71(2):201-30.
Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.