Congestive heart failure AHA recommendations for patients with reduced left ventricular ejection fraction: Difference between revisions
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==Overview== | ==Overview== | ||
==ACC/AHA Guidelines- Patients With Reduced Left Ventricular Ejection Fraction (DO NOT EDIT) <ref name=" | ==ACC/AHA Guidelines- Patients With Reduced Left Ventricular Ejection Fraction (DO NOT EDIT) <ref name="pmid16160202">Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al. (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16160202 ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society.] ''Circulation'' 112 (12):e154-235. [http://dx.doi.org/10.1161/CIRCULATIONAHA.105.167586 DOI:10.1161/CIRCULATIONAHA.105.167586] PMID: [http://pubmed.gov/16160202 16160202]</ref><ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation.] ''Circulation'' 119 (14):1977-2016. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref>== | ||
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===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]=== | ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]=== | ||
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'''4.''' [[Angiotensin II receptor blockers]] are recommended in patients with current or prior symptoms of [[HF]] and [[EF|reduced LVEF]] who are [[ACEI|ACE inhibitor]]-intolerant. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' | '''4.''' [[Angiotensin II receptor blockers]] are recommended in patients with current or prior symptoms of [[HF]] and [[EF|reduced LVEF]] who are [[ACEI|ACE inhibitor]]-intolerant. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' | ||
'''5.''' Drugs known to adversely affect the clinical status of patients with current or prior symptoms of [[HF]] and [[EF|reduced LVEF]] should be avoided or withdrawn whenever possible (e.g., [[NSAIDs|nonsteroidal anti-inflammatory drugs]], most [[antiarrhythmic drugs]], and most [[CCB|calcium channel blocking drugs]]). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''}} | '''5.''' Drugs known to adversely affect the clinical status of patients with current or prior symptoms of [[HF]] and [[EF|reduced LVEF]] should be avoided or withdrawn whenever possible (e.g., [[NSAIDs|nonsteroidal anti-inflammatory drugs]], most [[antiarrhythmic drugs]], and most [[CCB|calcium channel blocking drugs]]). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' | ||
'''6.''' Exercise training is beneficial as an adjunctive approach to improve clinical status in ambulatory patients with current or prior symptoms of [[HF]] and [[EF|reduced LVEF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' | |||
'''7.''' An implantable cardioverter-defibrillator is recommended as secondary prevention to prolong survival in patients with current or prior symptoms of [[HF]] and [[EF|reduced LVEF]] who have a history of [[cardiac arrest]], [[ventricular fibrillation]], or hemodynamically destabilizing [[ventricular tachycardia]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' | |||
'''8.''' Implantable cardioverter-defibrillator therapy is recommended for primary prevention of [[sudden cardiac death]] to reduce total mortality in patients with | |||
[[non-ischemic dilated cardiomyopathy]] or [[ischemic heart disease]] at least 40 days [[MI|post-MI]], a [[EF|LVEF]] less than or equal to 35%, and [[New york heart association functional classification|NYHA functional class II or III]] symptoms while receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' | |||
'''9.''' Patients with [[EF|LVEF]] of less than or equal to 35%, sinus rhythm, and [[New york heart association functional classification|NYHA functional class III or ambulatory class IV]] symptoms despite recommended, optimal medical therapy and who have cardiac dys-synchrony, which is currently defined as a QRS duration greater than or equal to 0.12 seconds, should receive [[cardiac resynchronization therapy]], with or without an [[ICD]], unless contraindicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' | |||
'''10.''' Addition of an [[aldosterone antagonist]] is recommended in selected patients with moderately severe to severe symptoms of [[HF]] and [[EF|reduced LVEF]] who can be carefully monitored for preserved renal function and normal potassium concentration. [[Creatinine]] should be 2.5 mg per dL or less in men or 2.0 mg per dL or less in women and potassium should be less than 5.0mEq per liter. Under circumstances where monitoring for hyperkalemia or renal dysfunction is not anticipated to be feasible, the risks may outweigh the benefits of aldosterone antagonists. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' | |||
'''11.''' The combination of [[hydralazine]] and [[nitrates]] is recommended to improve outcomes for patients selfdescribed as African-Americans, with moderate-severe symptoms on optimal therapy with [[ACEI|ACE inhibitors]], [[beta blockers]], and [[diuretics]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' | |||
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]=== | |||
'''1.''' It is reasonable to treat patients with [[atrial fibrillation]] and [[HF]] with a strategy to maintain sinus rhythm or with a strategy to control ventricular rate alone. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' | |||
'''2.''' Maximal exercise testing with or without measurement of respiratory gas exchange is reasonable to facilitate prescription of an appropriate exercise program for patients presenting with [[HF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' | |||
'''3.''' [[Angiotensin II receptor blockers]] are reasonable to use as alternatives to [[ACEI|ACE inhibitors]] as first-line therapy for patients with mild to moderate [[HF]] and [[EF|reduced LVEF]], especially for patients already taking [[ARB|ARBs]] for other indications. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' | |||
'''4.''' [[Digitalis]] can be beneficial in patients with current or prior symptoms of [[HF]] and [[EF|reduced LVEF]] to decrease hospitalizations for [[HF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' | |||
'''5.''' The addition of a combination of [[hydralazine]] and a [[nitrate]] is reasonable for patients with [[EF|reduced LVEF]] who are already taking an [[ACEI|ACE inhibitor]] and [[beta blocker]] for symptomatic [[HF]] and who have persistent symptoms. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' | |||
'''6.''' For patients who have [[EF|LVEF]] less than or equal to 35%, a QRS duration of greater than or equal to 0.12 seconds, and [[atrial fibrillation]], [[CRT]] with or without | |||
an [[ICD]] is reasonable for the treatment of [[NYHA classification|NYHA functional class III or ambulatory class IV]] heart failure symptoms on optimal recommended medical therapy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' | |||
'''7.''' For patients with [[EF|LVEF]] of less than or equal to 35% with [[NYHA classification|NYHA functional class III or ambulatory class IV]] symptoms who are receiving optimal recommended medical therapy and who have frequent dependence on ventricular pacing, [[CRT]] is reasonable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' | |||
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]=== | |||
'''1.''' A combination of hydralazine and a nitrate might be reasonable in patients with current or prior symptoms of [[HF]] and [[EF|reduced LVEF]] who cannot be given an [[ACEI|ACE inhibitor]] or [[ARB]] because of drug intolerance, [[hypotension]], or [[renal insufficiency]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' | |||
'''2.''' The addition of an ARB may be considered in persistently symptomatic patients with [[EF|reduced LVEF]] who are already being treated with conventional therapy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' | |||
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]=== | |||
'''1.''' Routine combined use of an [[ACEI|ACE inhibitor]], [[ARB]], and [[aldosterone antagonist]] is not recommended for patients with current or prior symptoms of [[HF]] and [[EF|reduced LVEF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' | |||
'''2.''' [[CCB|Calcium channel blocking drugs]] are not indicated as routine treatment for [[HF]] in patients with current or prior symptoms of [[HF]] and [[EF|reduced LVEF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' | |||
'''3.''' Long-term use of an infusion of a positive inotropic drug may be harmful and is not recommended for patients with current or prior symptoms of [[HF]] and [[EF|reduced LVEF]], except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' | |||
'''4.''' Use of nutritional supplements as treatment for [[HF]] is not indicated in patients with current or prior symptoms of [[HF]] and [[EF|reduced LVEF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' | |||
'''5.''' Hormonal therapies other than to replete deficiencies are not recommended and may be harmful to patients with current or prior symptoms of [[HF]] and [[EF|reduced LVEF]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''}} | |||
==Vote on and Suggest Revisions to the Current Guidelines== | ==Vote on and Suggest Revisions to the Current Guidelines== | ||
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==Guidelines Resources== | ==Guidelines Resources== | ||
*[http://circ.ahajournals.org/content/112/12/e154.full.pdf The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult] <ref name=" | *[http://circ.ahajournals.org/content/112/12/e154.full.pdf The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult] <ref name="pmid16160202">Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al. (2005) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=16160202 ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society.] ''Circulation'' 112 (12):e154-235. [http://dx.doi.org/10.1161/CIRCULATIONAHA.105.167586 DOI:10.1161/CIRCULATIONAHA.105.167586] PMID: [http://pubmed.gov/16160202 16160202]</ref> | ||
*[http://content.onlinejacc.org/cgi/reprint/53/15/1343.pdf 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation] <ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation.] ''Circulation'' 119 (14):1977-2016. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref> | *[http://content.onlinejacc.org/cgi/reprint/53/15/1343.pdf 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation] <ref name="pmid19324967">Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=19324967 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation.] ''Circulation'' 119 (14):1977-2016. [http://dx.doi.org/10.1161/CIRCULATIONAHA.109.192064 DOI:10.1161/CIRCULATIONAHA.109.192064] PMID: [http://pubmed.gov/19324967 19324967]</ref> | ||
Revision as of 03:05, 2 November 2011
| Heart failure | |
| ICD-10 | I50.0 |
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| ICD-9 | 428.0 |
| DiseasesDB | 16209 |
| MedlinePlus | 000158 |
| MeSH | D006333 |
| Congestive Heart Failure Microchapters |
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Pathophysiology |
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Differentiating Congestive heart failure from other Diseases |
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Diagnosis |
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Treatment |
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Medical Therapy: |
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Surgical Therapy: |
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ACC/AHA Guideline Recommendations
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Specific Groups: |
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Congestive heart failure AHA recommendations for patients with reduced left ventricular ejection fraction On the Web |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
ACC/AHA Guidelines- Patients With Reduced Left Ventricular Ejection Fraction (DO NOT EDIT) [1][2]
| “ |
Class I1. Diuretics and salt restriction are indicated in patients with current or prior symptoms of HF and reduced LVEF who have evidence of fluid retention. (Level of Evidence: C) 2. Angiotensin-converting enzyme inhibitors are recommended for all patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated. (Level of Evidence: A) 3. Beta blockers (using 1 of the 3 proven to reduce mortality, i.e., bisoprolol, carvedilol, and sustained release metoprolol succinate) are recommended for all stable patients with current or prior symptoms of HF and reduced LVEF, unless contraindicated. (Level of Evidence: A) 4. Angiotensin II receptor blockers are recommended in patients with current or prior symptoms of HF and reduced LVEF who are ACE inhibitor-intolerant. (Level of Evidence: A) 5. Drugs known to adversely affect the clinical status of patients with current or prior symptoms of HF and reduced LVEF should be avoided or withdrawn whenever possible (e.g., nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking drugs). (Level of Evidence: B) 6. Exercise training is beneficial as an adjunctive approach to improve clinical status in ambulatory patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: B) 7. An implantable cardioverter-defibrillator is recommended as secondary prevention to prolong survival in patients with current or prior symptoms of HF and reduced LVEF who have a history of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular tachycardia. (Level of Evidence: A) 8. Implantable cardioverter-defibrillator therapy is recommended for primary prevention of sudden cardiac death to reduce total mortality in patients with non-ischemic dilated cardiomyopathy or ischemic heart disease at least 40 days post-MI, a LVEF less than or equal to 35%, and NYHA functional class II or III symptoms while receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year. (Level of Evidence: A) 9. Patients with LVEF of less than or equal to 35%, sinus rhythm, and NYHA functional class III or ambulatory class IV symptoms despite recommended, optimal medical therapy and who have cardiac dys-synchrony, which is currently defined as a QRS duration greater than or equal to 0.12 seconds, should receive cardiac resynchronization therapy, with or without an ICD, unless contraindicated. (Level of Evidence: A) 10. Addition of an aldosterone antagonist is recommended in selected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal potassium concentration. Creatinine should be 2.5 mg per dL or less in men or 2.0 mg per dL or less in women and potassium should be less than 5.0mEq per liter. Under circumstances where monitoring for hyperkalemia or renal dysfunction is not anticipated to be feasible, the risks may outweigh the benefits of aldosterone antagonists. (Level of Evidence: B) 11. The combination of hydralazine and nitrates is recommended to improve outcomes for patients selfdescribed as African-Americans, with moderate-severe symptoms on optimal therapy with ACE inhibitors, beta blockers, and diuretics. (Level of Evidence: B) Class IIa1. It is reasonable to treat patients with atrial fibrillation and HF with a strategy to maintain sinus rhythm or with a strategy to control ventricular rate alone. (Level of Evidence: A) 2. Maximal exercise testing with or without measurement of respiratory gas exchange is reasonable to facilitate prescription of an appropriate exercise program for patients presenting with HF. (Level of Evidence: C) 3. Angiotensin II receptor blockers are reasonable to use as alternatives to ACE inhibitors as first-line therapy for patients with mild to moderate HF and reduced LVEF, especially for patients already taking ARBs for other indications. (Level of Evidence: A) 4. Digitalis can be beneficial in patients with current or prior symptoms of HF and reduced LVEF to decrease hospitalizations for HF. (Level of Evidence: B) 5. The addition of a combination of hydralazine and a nitrate is reasonable for patients with reduced LVEF who are already taking an ACE inhibitor and beta blocker for symptomatic HF and who have persistent symptoms. (Level of Evidence: B) 6. For patients who have LVEF less than or equal to 35%, a QRS duration of greater than or equal to 0.12 seconds, and atrial fibrillation, CRT with or without an ICD is reasonable for the treatment of NYHA functional class III or ambulatory class IV heart failure symptoms on optimal recommended medical therapy. (Level of Evidence: B) 7. For patients with LVEF of less than or equal to 35% with NYHA functional class III or ambulatory class IV symptoms who are receiving optimal recommended medical therapy and who have frequent dependence on ventricular pacing, CRT is reasonable. (Level of Evidence: C) Class IIb1. A combination of hydralazine and a nitrate might be reasonable in patients with current or prior symptoms of HF and reduced LVEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency. (Level of Evidence: C) 2. The addition of an ARB may be considered in persistently symptomatic patients with reduced LVEF who are already being treated with conventional therapy. (Level of Evidence: B) Class III1. Routine combined use of an ACE inhibitor, ARB, and aldosterone antagonist is not recommended for patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: C) 2. Calcium channel blocking drugs are not indicated as routine treatment for HF in patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: A) 3. Long-term use of an infusion of a positive inotropic drug may be harmful and is not recommended for patients with current or prior symptoms of HF and reduced LVEF, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment. (Level of Evidence: C) 4. Use of nutritional supplements as treatment for HF is not indicated in patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: C) 5. Hormonal therapies other than to replete deficiencies are not recommended and may be harmful to patients with current or prior symptoms of HF and reduced LVEF. (Level of Evidence: C) |
” |
Vote on and Suggest Revisions to the Current Guidelines
Guidelines Resources
- The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult [1]
- 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation [2]
References
- ↑ 1.0 1.1 Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al. (2005) ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 112 (12):e154-235. DOI:10.1161/CIRCULATIONAHA.105.167586 PMID: 16160202
- ↑ 2.0 2.1 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967