2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults

1. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults Mariell L. Jessup, William T. Abraham, Donald E. Casey, Arthur M. Feldman, Gary S. Francis, Theodore G. Ganiats, Marvin A. Konstam, Donna M. Mancini, Peter S. Rahko, Marc A. Silver, Lynne Warner Stevenson, and Clyde W. Yancy Journal of the American College of Cardiology 2009;53;1343-1382

2. Initial Clinical Assessment of Patients Presenting With Heart Failure Class IIa Level A • Measurement of BNP or NT-proBNP • Useful in the evaluation of patients presenting in the urgent care setting in whom the clinical diagnosis is uncertain and can be helpful in risk stratification • Note: Recommendation modified to expand the use of BNP and NT-proBNP within the context of the overall evaluation of the patient Jessup M et al. J Am Coll Cardiol. 2009;53;1343-82.

3. Patients With Reduced Left Ventricular Ejection Fraction Class I Level A • Implantable Cardioverter-Defibrillator (ICD) therapy • Patients with nonischemic dilated cardiomyopathy • Ischemic heart disease > 40 days post-myocardial infarction • LVEF less than or equal to 35%, NYHA functional class II or III symptoms while receiving chronic optimal medical therapy • Reasonable expectation of survival with a good functional status > 1 year • Cardiac resynchronization therapy with or without ICD • LVEF less than or equal to 35%, sinus rhythm, and NYHA functional class III or ambulatory class IV symptoms and cardiac dyssynchrony Class I Level B • Hydralazine and nitrates • African-Americans, with moderate-severe symptoms on optimal therapy with ACE inhibitors, beta blockers, and diuretics Jessup M et al. J Am Coll Cardiol. 2009;53;1343-82.

4. Patients With Reduced Left Ventricular Ejection Fraction Class IIa Level A • Strategy to maintain sinus rhythm or control ventricular rate alone • Presentation of atrial fibrillation and HF Class IIa Level C • Maximal exercise testing with or without measurement of respiratory gas exchange to facilitate prescription of an appropriate exercise program for patients presenting with heart failure (HF) Jessup M et al. J Am Coll Cardiol. 2009;53;1343-82.

5. Patients With Reduced Left Ventricular Ejection Fraction Class IIa Level B • Cardiac resynchronization therapy with or without ICD • LVEF less than or equal to 35%, QRS duration of greater than or equal to 0.12 seconds, and atrial fibrillation • NYHA functional class III or ambulatory class IV HF symptoms on optimal recommended medical therapy Class IIa Level C • Cardiac resynchronization therapy • LVEF of less than or equal to 35%, NYHA functional class III or ambulatory class IV symptoms • Dependence on ventricular pacing Jessup M et al. J Am Coll Cardiol. 2009;53;1343-82.

6. Patients With Refractory End-Stage Heart Failure (Stage D) Class III Level A • Routine intermittent infusions of vasoactive and positive inotropic agents are not recommended for patients with refractory end-stage HF Jessup M et al. J Am Coll Cardiol. 2009;53;1343-82.

7. The Hospitalized Patient: Class I • Full assessments are recommended • Adequacy of systemic perfusion and volume status • Precipitating factors and/or comorbidities • Determine if HF is new onset or an exacerbation of chronic disease and whether it is associated with preserved ejection fraction • Chest radiographs, electrocardiogram, and echocardiography are key tests • BNP and NT-BNP • Dyspnea in which the contribution of HF is not known • Final diagnosis requires interpreting these results in the context of all available clinical data • Oxygen therapy should be administered to relieve symptoms related to hypoxemia BNP Jessup M et al. J Am Coll Cardiol. 2009;53;1343-82.

8. The Hospitalized Patient: Class I • Rapid intervention to improve systemic perfusion • Rapid decompensation and hypoperfusion associated with decreasing urine output and other manifestations of shock • Intravenous loop diuretics immediately • Patients admitted with HF and with evidence of significant fluid overload • If patient is already receiving loop diuretic therapy, initial intravenous dose should equal or exceed their chronic oral daily dose. • When diuretic regimen is inadequate to relieve congestion • Higher doses of loop diuretics • Addition of a second diuretic or continuous infusion of a loop diuretic Jessup M et al. J Am Coll Cardiol. 2009;53;1343-82.

9. The Hospitalized Patient: Class I • Intravenous inotropic or vasopressor drugs to maintain systemic perfusion • Clinical evidence of hypotension associated with hypoperfusion and obvious evidence of elevated cardiac filling pressures • Invasive hemodynamic monitoring • Patients who are in respiratory distress • Clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment • Medications should be reconciled in every patient and adjusted as appropriate on admission to and discharge from the hospital Jessup M et al. J Am Coll Cardiol. 2009;53;1343-82.

10. The Hospitalized Patient: Class I • Continued ACE inhibitors or ARBs and beta-blocker therapy • Patients with reduced ejection fraction experiencing a symptomatic exacerbation of HF • Requiring hospitalization during chronic maintenance treatment with oral therapies known to improve outcomes • Initiation of ACE inhibitors or ARBs and beta-blocker therapy • Patients hospitalized with HF with reduced ejection fraction not treated with oral therapies known to improve outcomes • Initiation of beta-blocker therapy • After optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents Jessup M et al. J Am Coll Cardiol. 2009;53;1343-82.

11. The Hospitalized Patient: Class I • Transition from intravenous to oral diuretic therapy • In all patients hospitalized with HF, both with preserved and low EF • Comprehensive written discharge instructions • All patients with a hospitalization for HF and their caregivers • Post-discharge systems of care should be used to facilitate transition to effective outpatient care Jessup M et al. J Am Coll Cardiol. 2009;53;1343-82.

12. The Hospitalized Patient: Class IIa • Urgent cardiac catheterization (if likely to prolong meaningful survival) • Presentation of acute HF and known or suspected acute myocardial ischemia due to occlusive coronary disease • Vasodilators • Evidence of severely symptomatic fluid overload in the absence of systemic hypotension • Ultrafiltration is reasonable for patients with refractory congestion not responding to medical therapy Jessup M et al. J Am Coll Cardiol. 2009;53;1343-82.

13. The Hospitalized Patient: Class IIa • Invasive hemodynamic monitoring for carefully selected patients with acute HF • Persistent symptoms despite empiric adjustment of standard therapies • Fluid status, perfusion, or systemic or pulmonary vascular resistances are uncertain • Systolic pressure remains low, or is associated with symptoms, despite initial therapy • Renal function is worsening with therapy • Require parenteral vasoactive agents • May need consideration for device therapy or transplantation Jessup M et al. J Am Coll Cardiol. 2009;53;1343-82.

14. The Hospitalized Patient Class IIb • Intravenous inotropic drugs such as dopamine, dobutamine or milrinone (maintain systemic perfusion and preserve end-organ performance) • Patients with severe systolic dysfunction, low blood pressure and evidence of low cardiac output, with or without congestion Class III • Parenteral inotropes in normotensive patients with acute decompensated HF without evidence of decreased organ perfusion is not recommended • Routine use of invasive hemodynamic monitoring in normotensive patients with acute decompensated HF and congestion with symptomatic response to diuretics and vasodilators is not recommended Jessup M et al. J Am Coll Cardiol. 2009;53;1343-82.

15. Treatment of Special Populations Class I Level A • African Americans: NYHA functional class III or IV HF • Combination of a fixed dose of isosorbide dinitrate and hydralazine to a standard medical regimen for HF, including ACE inhibitors and beta blockers Jessup M et al. J Am Coll Cardiol. 2009;53;1343-82.