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New Recommendations

New Recommendations. HFSA 2010 Comprehensive Heart Failure Practice Guideline. HFSA 2010 Practice Guideline Evaluation of MI. Recommendation 4.16 (NEW in 2010)

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New Recommendations

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  1. New Recommendations HFSA 2010 Comprehensive Heart Failure Practice Guideline

  2. HFSA 2010 Practice GuidelineEvaluation of MI • Recommendation 4.16(NEW in 2010) • Evaluation of myocardial ischemia is recommended in those who develop new-onset LV systolic dysfunction, especially in the setting of suspected MI or worsening symptoms with pre-existing CAD. The choice of testing modality should depend on the clinical suspicion and underlying cardiac risk factors. • Coronary angiography should be considered when pre-test probability of underlying ischemic cardiomyopathy is high and an invasive coronary intervention may be considered. See Section 13 for specific clinical situations and Strength of Evidence.

  3. HFSA 2010 Practice GuidelineNonpharmacologic—Exercise Training • Recommendation 6.19(NEW in 2010) • It is recommended that patients with HF undergo exercise testing to determine suitability for exercise training (patient does not develop significant ischemia or arrhythmias). If deemed safe, exercise training should be considered for patients with HF in order to: • Facilitate understanding of exercise expectations (heart rate ranges and appropriate levels of exercise training) • Increase exercise duration and intensity in a supervised setting • Promote adherence to a general exercise goal of 30 minutes of moderate activity/exercise, 5 days per week with warm up and cool down exercises Strength of Evidence = B

  4. HFSA 2010 Practice GuidelineARBs • Recommendation 7.13(NEW in 2010) • The addition of an ARB should be considered in patients with HF due to reduced LVEF who have persistent symptoms or progressive worsening despite optimized therapy with an ACE inhibitor and beta blocker. • Strength of Evidence = A

  5. HFSA 2010 Practice GuidelineAmiodarone • Recommendation 7.40 (NEW in 2010) • Routine use of amiodarone therapy for asymptomatic arrhythmias that are not felt to contribute to HF or ventricular dysfunction is not recommended. Strength of Evidence = B

  6. HFSA 2010 Practice GuidelinePUFA • Recommendation 7.41 (NEW in 2010) • n-3 polyunsaturated fatty acids (PUFA) may be considered to reduce mortality in HF patients with NYHA class II-IV symptoms and reduced LVEF. Strength of Evidence = B

  7. HFSA 2010 Practice GuidelineEnd-of-Life Care • Recommendation 8.16(NEW in 2010) • It is recommended that, as part of end-of-life care, patients and their families/caregivers have a plan to manage a sudden decompensation, death, or progressive decline. • Inactivation of an implantable defibrillation device should be discussed in the context of allowing natural death at end of life. A process for deactivating defibrillators should be clarified in all settings in which patients with HF receive care. Strength of Evidence = C

  8. HFSA 2010 Practice GuidelineBiventricular Pacing • Recommendation 9.8(NEW in 2010) • Biventricular pacing therapy may be considered for patients with AF with a widened QRS interval (≥ 120 ms) and severe LV systolic dysfunction (LVEF ≤ 35%) who have persistent, moderate to severe HF (NYHA III) despite optimal medical therapy. • Strength of Evidence = A

  9. HFSA 2010 Practice GuidelineBiventricular Pacing • Recommendation 9.11 (NEW in 2010) • In patients with reduced LVEF who require chronic pacing and in whom frequent ventricular pacing is expected, biventricular pacing may be considered. • Strength of Evidence = C

  10. HFSA 2010 Practice Guideline“Bridge to Decision” • Recommendation 10.7(NEW in 2010) • The following patients should be considered for urgent mechanical circulatory support as a “bridge to decision”: • Patients with refractory HF and hemodynamic instability • and/or compromised end-organ function • with relative contraindications to cardiac transplantation or permanent mechanical circulatory assistance, who are expected to improve with time or restoration of an improved hemodynamic profile • These patients should be referred to a center with expertise in the management of patients with advanced HF Strength of Evidence = C

  11. HFSA 2010 Practice GuidelineAcute HF--NIV • Recommendation 12.15(NEW in 2010) • Use of non-invasive positive pressure ventilation may be considered for severely dyspneic patients with clinical evidence of pulmonary edema. Strength of Evidence = C

  12. HFSA 2010 Practice GuidelineAcute HF—VT Prophylaxis • Recommendation 12.16(NEW in 2010) 1 of 2 • Venous thromboembolism prophylaxis with low dose unfractionated heparin, low molecular weight heparin, or fondaparinux to prevent proximal deep venous thrombosis and pulmonary embolism is recommended for patients who are admitted to the hospital with ADHF and who are not already anticoagulated and have no contraindication to anticoagulation. Strength of Evidence = B

  13. HFSA 2010 Practice GuidelineAcute HF—VT Prophylaxis • Recommendation 12.16(NEW in 2010) 2 of 2 • Venous thromboembolism prophylaxis with a mechanical device (intermittent pneumatic compression devices or graded compression stockings ) to prevent proximal deep venous thrombosis and pulmonary embolism should be considered for patients who are admitted to the hospital with ADHF, who are not already anticoagulated, and who have acontraindication to anticoagulation. Strength of Evidence = C

  14. HFSA 2010 Practice GuidelineHF in Women • Recommendation 15.6(NEW in 2010) • ARBs are recommended for administration to symptomatic and asymptomatic women with an LVEF ≤ 40% who are intolerant to ACE inhibitors for reasons other than hyperkalemia or renal insufficiency. • Strength of Evidence = A

  15. HFSA 2010 Practice GuidelineHF in African Americans • Recommendation 15.7(NEW in 2010) • The combination of hydralazine/isosorbide dinitrate is recommended as standard therapy for African American women with moderate to severe HF symptoms who are on background neurohormonal inhibition. Strength of Evidence = B

  16. Genetic Evaluation of Cardiomyopathy HFSA 2010 Recommendations New Section

  17. HFSA 2010 Practice GuidelineGenetic Evaluation—Family History • Recommendation 17.1 • A careful family history for ≥3 generations is recommended for all patients with cardiomyopathy. • Hypertrophic cardiomyopathy Strength of Evidence = A • Dilated cardiomyopathy Strength of Evidence = A • Arrhythmogenic right ventricular dysplasia Strength of Evidence = A • Left ventricular noncompaction Strength of Evidence = A • Restrictive cardiomyopathy Strength of Evidence = B • Cardiomyopathies associated with extracardiac manifestations Strength of Evidence = A

  18. HFSA 2010 Practice GuidelineGenetic Evaluation—Clinical Screening • Recommendation 17.2.a • Clinical screening for cardiomyopathy in asymptomatic first-degree relatives is recommended. • a. Cardiomyopathy phenotype: • Hypertrophic cardiomyopathy Strength of Evidence = A • Dilated cardiomyopathy Strength of Evidence = A • Arrhythmogenic RV dysplasia Strength of Evidence = A • Left ventricular noncompaction Strength of Evidence = B • Restrictive cardiomyopathy Strength of Evidence = B • Cardiomyopathies associated with extracardiac manifestations Strength of Evidence = A

  19. HFSA 2010 Practice GuidelineGenetic Evaluation—Clinical Screening • Recommendation 17.2.b and c • b. Clinical screening for cardiomyopathy is recommended at intervals (see 17.2.e) in asymptomatic at-risk relatives who are known to carry the disease-causing mutations. Strength of Evidence = A • c. Clinical screening for cardiomyopathy is recommended for asymptomatic at-risk first-degree relatives when genetic testing has not been performed or has not identified a disease-causing mutation. Strength of Evidence = A

  20. HFSA 2010 Practice GuidelineGenetic Evaluation—Clinical Screening • Recommendation 17.2.d • d. It is recommended that clinical screening consist of: • History (with special attention fo HF symptoms, arrhythmias, presyncope and syncope) • Physical examination (with special attention to the cardiac and skeletal muscle systems) • Electrocardiogram and echocardiogram • CK-MM (at initial evaluation only) • Signal-averaged electrocardiogram (SAECG) in ARVD only • Holter monitoring in HCM, ARVD • Exercise treadmill testing in HCM • MRI in ARVD Strength of Evidence = B

  21. HFSA 2010 Practice Guideline Recommendation 17.2.e. Clinical screening for cardiomyopathy should be considered at the following times and intervals or at any time signs or symptoms appear.

  22. HFSA 2010 Practice GuidelineGenetic Evaluation—Clinical Screening • Recommendation 17.2.f • f. At-risk first-degree relatives with any abnormal clinical screening tests (regardless of genotype) should be considered for repeat clinical screening at 1 year. Strength of Evidence = C

  23. HFSA 2010 Practice GuidelineGenetic Evaluation—Referral • Recommendation 17.3 • Evaluation, genetic counseling, and genetic testing of cardiomyopathy patients are complex processes. Referral to centers expert in genetic evaluation and family-based management should be considered.Strength of Evidence = B

  24. HFSA 2010 Practice GuidelineGenetic Evaluation—Testing • Recommendation 17.4.a • Genetic testing should be considered for the one most clearly affected person in a family to facilitate family screening and management. • a. Cardiomyopathy phenotype: • Hypertrophic cardiomyopathy Strength of Evidence = A • Dilated cardiomyopathy Strength of Evidence = B • Arrhythmogenic RV dysplasia Strength of Evidence = A • Left ventricular noncompaction Strength of Evidence = C • Restrictive cardiomyopathy Strength of Evidence = C • Cardiomyopathies associated with extracardiac manifestations Strength of Evidence = A

  25. HFSA 2010 Practice Guideline Recommendation 17.4.b. Specific genes available for screening based on cardiac phenotype

  26. HFSA 2010 Practice GuidelineGenetic Evaluation—Testing • GeneTests (www.genetests.org) • An NIH-funded resource that lists clinical (and research) molecular genetic testing laboratories for the cardiomyopathies.

  27. HFSA 2010 Practice GuidelineGenetic Evaluation—Testing • Recommendation 17.4.c • Screening for Fabry disease is recommended in all men with sporadic or non-autosomal dominant (no male-to-male) transmission of unexplained cardiac hypertrophy.Strength of Evidence = B

  28. HFSA 2010 Practice GuidelineGenetic Evaluation—Counseling • Recommendation 17.5 • Genetic and family counseling is recommended for all patients and families with cardiomyopathy.Strength of Evidence = A

  29. HFSA 2010 Practice GuidelineGenetic Evaluation—Medical Therapy • Recommendation 17.6 • Medical therapy based on cardiac phenotype is recommended. • Strength of Evidence = A

  30. HFSA 2010 Practice GuidelineGenetic Evaluation—Device Therapy • Recommendation 17.7 • Device therapies for arrhythmia and conduction system disease based on cardiac phenotype are recommended.Strength of Evidence = B

  31. HFSA 2010 Practice GuidelineGenetic Evaluation—ICDs • Recommendation 17.8 • In patients with cardiomyopathy and significant arrhythmia or known risk of arrhythmia, an ICD may be considered before the LVEF falls below 35%.Strength of Evidence = C

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