ACCF/AHA 2013 Guidelines for Managing Heart Failure
Background
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.
Guideline Update
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.
