2017 ACC/AHA/HFSA Focused Update Guideline for the Management of Heart Failure

Authors:
Yancy CW, Jessup M, Bozkurt B, et al.
Citation:
2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. J Am Coll Cardiol 2017;Apr 28:[Epub ahead of print].

The following are summary points to remember about the 2017 American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure (HF):

Biomarkers:

  • For prevention: The 2017 Focused Update gives a Class IIa recommendation (Level of Evidence: B-R) for utilizing natriuretic peptide biomarker-based screening for those at risk of developing HF, followed by team-based care including a cardiovascular specialist optimizing guideline-directed medical therapy (GDMT), to prevent the development of left ventricular dysfunction (systolic or diastolic) or new-onset HF.
  • For diagnosis: The 2017 Focused Update gives a Class I recommendation (Level of Evidence: A) for measurement of natriuretic peptide biomarkers in patients presenting with dyspnea, to support a diagnosis or exclusion of HF.
  • For prognosis or added risk stratification: The 2017 Focused Update gives a:
    • Class I recommendation (Level of Evidence: A) for measurement of B-type natriuretic peptide (BNP) or N-terminal (NT)-proBNP for establishing prognosis or disease severity in chronic HF.
    • Class I recommendation (Level of Evidence: A) for measurement of baseline natriuretic peptide biomarkers and/or cardiac troponin on admission to the hospital to establish a prognosis in acutely decompensated HF.
    • Class IIa recommendation (Level of Evidence: B-NR) for measurement of a predischarge natriuretic peptide level during a HF hospitalization, to establish a post-discharge prognosis.
    • Class IIa recommendation (Level of Evidence: B-NR) for measurement of other clinically available tests, such as biomarkers of myocardial injury or fibrosis, in patients with chronic HF for additive risk stratification.

Stage C HF With Reduced Ejection Fraction (HFrEF): Summarized earlier here in a previous Journal Scan on the HF Focused Update on Pharmacological Therapy.

Stage C HF With Preserved EF (HFpEF): The 2017 Focused Update gives the following:

  • Class IIa recommendation (Level of Evidence: B-R) for use of aldosterone antagonists in appropriately selected patients with HFpEF (with EF ≥45%, elevated BNP or HF admission within 1 year, estimated glomerular filtration rate >30 and creatinine <2.5 mg/dl, potassium <5.0 mEq /L), to decrease hospitalizations.
  • Class III recommendation (Level of Evidence: B-R) for routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or quality of life (QoL) in patients with HFpEF, as there is no benefit.
  • Class III recommendation (Level of Evidence: B-C) for routine use of nutritional supplements in patients with HFpEF, as there is no benefit.

Anemia: The 2017 Focused Update gives a:

  • Class IIb recommendation (Level of Evidence: B-R) for intravenous iron replacement in patients with New York Heart Association (NYHA) class II and III HF and iron deficiency (ferritin <100 ng/ml or 100-300 ng/ml if transferrin saturation <20%), to improve functional status and QoL.
  • Class III recommendation (Level of Evidence: B-R) that erythropoietin stimulating agents should not be used in patients with HF and anemia to improve morbidity and mortality, as there is no benefit.

Hypertension: The 2017 Focused Update gives a:

  • Class I recommendation (Level of Evidence: B-R) for targeting an optimal blood pressure (BP) of <130/80 mm Hg in those with hypertension and at increased risk (stage A HF).
  • Class I recommendation (Level of Evidence: C-EO) for titration of GDMT to attain systolic BP (SBP) <130 mm Hg in patients with HFrEF and hypertension.
  • Class I recommendation (Level of Evidence: C-LD) for titration of GDMT to attain SBP <130 mm Hg in patients with HFpEF and persistent hypertension after management of volume overload.

Sleep-Disordered Breathing: The 2017 Focused Update gives a:

  • Class IIa recommendation (Level of Evidence: C-LD) for a formal sleep assessment in patients with NYHA class II–IV HF and suspicion of sleep-disordered breathing or excessive daytime sleepiness.
  • Class IIb recommendation (Level of Evidence: B-R) for utilization of continuous positive airway pressure in patients with cardiovascular disease and obstructive sleep apnea, to improve sleep quality and daytime sleepiness.
  • Class III recommendation: Harm (Level of Evidence: B-R) for use of adaptive servo-ventilation in patients with NYHA class II–IV HFrEF and central sleep apnea, as it causes harm.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Heart Transplant, Mechanical Circulatory Support, Interventions and Vascular Medicine, Hypertension, Sleep Apnea

Keywords: Anemia, Biological Markers, Cardiac Resynchronization Therapy, Cardiomyopathies, Defibrillators, Implantable, Guideline, Heart-Assist Devices, Heart Failure, Heart Transplantation, Hypertension, Palliative Care, Peripheral Vascular Diseases, Practice Guideline, Risk Assessment, Risk Factors, Sleep Apnea Syndromes, Vascular Surgical Procedures


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