A new ACC expert consensus decision pathway aims to help streamline treatment of patients with heart failure and ensure the best possible patient outcomes by addressing 10 "pivotal" issues that remain unresolved in clinical guidelines.

"Heart failure care has become increasingly complex with multiple medications that are evidence-based, several choices of devices and an array of process of care interventions," said Clyde W. Yancy, MD, MSc, MACC, chair of the writing committee. "Despite new guideline statements, information voids exist, and a practical, consensus approach is needed for areas that have incomplete evidence."

The new document complements the 2017 ACC/AHA/HFSA Focused Update of the 2013 ACC/AHA Guideline for the Management of Heart Failure by addressing new medical therapies, prevention and comorbidities relevant to heart failure with reduced ejection fraction for which data are available. Specifically, the document focuses on the following 10 areas:

1. How to initiate, add or switch therapy to new evidence-based guideline-directed treatments for heart failure with reduced ejection fraction
2. How to achieve optimal therapy given multiple drugs for heart failure including augmented clinical assessment that may trigger additional changes in guideline-directed therapy (e.g., imaging data, biomarkers, and filling pressures)
3. When to refer to a heart failure specialist
4. How to address challenges of care coordination
5. How to improve adherence
6. What is needed in specific patient cohorts: African Americans, the frail, and older adults
7. How to manage your patients' cost of care for heart failure
8. How to manage the increasing complexity of heart failure
9. How to manage common comorbidities
10. How to integrate palliative care and transition to hospice care

"These are the objectives that the everyday provider wants addressed," Yancy said.  "Achieving not just optimal therapy for HFrEF but an appropriate regimen for each patient given the prevailing clinical scenario is the goal."

According to Yancy, the document contains numerous algorithms of care, informative tables and important call-outs to emphasize best practices for consideration. "This Pathway document, plus subsequent digital-friendly tools, will hopefully provide a more rapid uptake of best treatment strategies and in turn support best outcomes for patients with heart failure," he said.

Each member of the writing committee—representative of all stakeholders—facilitated a separate survey with their own constituency to ensure that the document addressed and acknowledged as many needs as possible. In addition, the document was among the first of its kind to be open to public comment during peer review. During revisions of the document, public comments were given the same weight as those from the formal peer-review process. Moving forward, the writing committee suggests that this public-comments process may be a new way of developing documents, in the hope that it will allow consensus to follow much more quickly than before.

"There has been a challenge with implementation of guidelines across the board," Yancy said. "This document is not a guideline statement but a straightforward response to 10 pivotal issues and is a major step toward deploying aspects of implementation science as a means of improving adherence to evidence-based guideline-directed therapy."

This article contains educational materials intended for licensed health care professionals and is intended to be used solely for educational and informational purposes. While the content may be about specific medical and health care issues, it is not a substitute for or replacement of personalized medical advice and is not intended to be used as the sole basis for making individualized medical or health-related decisions. The views and opinions expressed are those of the contributing authors and editors and do not necessarily represent the views of the ACC. The material is not intended to present the only, or necessarily best, methods or procedures for the medical situations addressed, but rather is intended to represent an approach, view, statement or opinion.

Keywords: Stroke Volume, Goals, Palliative Care, Hospices, Heart Failure, Comorbidity, Clinical Protocols, Algorithms

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