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, 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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