Improving quality of care, optimizing patient outcomes, and efficiently using health care resources are all goals of new, expanded clinical practice guidelines for the management of patients with heart failure (HF). The ACCF and the American Heart Association document is a thorough reassessment of HF diagnosis and management that goes beyond the previous 2005 HF guidelines and corresponding 2009 focused update.

According to Clyde W. Yancy, MD, chair of the writing committee, "Given the public health imperative to address heart failure as a major driver of health care expenditures, it was important to 'get this right.'"

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, highlights include:

• A number of significant changes all meant to enhance the document's relevance at the point of care. As part of an ongoing improvement initiative, the new guidelines have limited narrative text, a focus on summary and evidence tables (with references linked to PubMed abstracts), and more liberal use of summary recommendation tables (with references that support level of evidence) to serve as a quick reference.
• Fewer recommendations have a "C" level of evidence, especially for class I recommended therapies. Level "C" evidence is based on very limited populations evaluated or evidence based on consensus opinion of experts, case studies, or standard of care.
• The 2013 guidelines address HF with preserved ejection fraction (EF) in more detail and similarly revisit the clinical management of hospitalization for acute HF.
• Additional areas of renewed interest include Stage D HF, palliative care, and the transition of and quality of care for HF.
• An algorithmic process can be used to guide best use of device-based therapeutics for HF, with as much emphasis on when not to deploy device-based therapy as on when the data are most supportive of such an approach.
• The imperative to focus on prevention is emphasized yet again and directives to consider more careful evaluations of patients with dilated cardiomyopathy, including consideration for genetic screening.

"Fully one-third of the writing committee's 2-year time investment was spent on reviewing the mass of evidence in heart failure and orchestrating those data in a series of online evidence tables," Dr. Yancy said. No longer just a bibliography list, "these tables provide searchable Pubmed ID numbers, a summary of the data, and a synopsis of the impact of those findings on heart failure outcomes." The end user will be able to easily review the source documentation for the majority of these guideline statements.

New Evidence Regarding Drugs and Devices

With a stronger evidence base, there are new recommendations relating to both drug- and device-based therapy. The use of aldosterone antagonists is strongly recommended and now includes patients with not only advanced HF, but also mild-to-moderate HF as well. "The evidence strongly supports improved outcomes" with aldosterone antagonists, according to Dr. Yancy, with the proviso that "renal function is reasonably intact."

Cardiac resynchronization therapy (CRT) similarly now has a stronger evidence base from multiple randomized controlled trials that also extend CRT to patients with mild-to-moderate HF. Importantly, sufficient data are now available to allow better discrimination of those who are most likely to benefit from CRT from those unlikely to benefit.

Since the 2009 focused update, there also are more data to substantiate the use of mechanical circulatory support for advanced HF. According to Dr. Yancy and his writing committee vice chair Mariell Jessup, MD, this is no longer a proof-of-concept strategy, noting "left ventricular assist devices for advanced chronic HF represent an important component of a contemporary treatment algorithm for heart failure."

Additionally, the guidelines better articulate the role of CABG for HF with severely reduced EF and CAD. The availability and success of transcutaneous aortic valve replacement has also merited mention in the 2013 guidelines.

Emphasis on GDMT

Like other recent guidelines, the new HF recommendations also use the designation GDMT. Given the advances in medical therapy across the spectrum of CVD, the term guideline-directed medical therapy (GDMT) represents optimal medical therapy as defined by ACCF/AHA guidelines (primarily Class I recommendations).

The guidelines encourage cardiologists to educate patients, family members, and other clinicians about the expected benefits of GDMT, including:

• the potential for myocardial reverse remodeling,
• increased survival,
• improved functional status, and
• better health-related quality of life.

More robust data also have permitted considerable expansion regarding the need for shared decision making in HF, quality-of-life improvement, advanced directives, palliative care, and hospice. Dr. Jessup said, "These areas are much more robustly represented in this guideline than before."

Finally, the expanded awareness of the multiple comorbidities that frequently exist in patients with HF is recognized and a separate section emphasizing the concomitant presence of AF is now a key component of the new guidelines.

Bottom line, according to the guidelines committee: "Adherence to the clinical practice guidelines should lead to improved patient outcomes."

Keywords: Writing, Advance Directives, Heart-Assist Devices, Documentation, Comorbidity, Awareness, Cardiac Resynchronization Therapy, Palliative Care, Public Health, Quality of Life, Heart Failure, Investments, Health Expenditures, Hospitalization

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