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Chronic Heart Failure

Chronic Heart Failure Clinical Guideline

The ACC/AHA/HFSA (Heart Failure Society of America) last released an update to the 2013 ACCF/AHA Guideline for the Management of Heart Failure titled: 2017 ACC/AHA/HFSA Focused Update of the 2013ACCF/AHA Guideline for the Management of Heart Failure. The key data that influenced guideline recommendations were reviewed clinical trials that were published in peer-reviewed format from April 2013 through November 2016.  New data is reviewed on an ongoing basis, with full guideline revisions commissioned in approximately 6-year cycles. Paramount’s Medical Advisory Council (MAC) adopted this updated guideline on October 9, 2018.

Some of the key highlights from the guideline are:

  • New data suggest that natriuretic peptide biomarker screening and early intervention may prevent HF. Class (Strength) of Recommendation (COR): IIA; and Level of Evidence (LOE): B-R.
  • In Patients with dyspnea, measurement of natriuretic peptide biomarkers is useful to support a diagnosis or exclusion of HF.COR: I; LOE: A.
  • During a HF hospitalization, a predischarge natriuretic peptide level can be useful to establish a post discharge prognosis.COR: IIa; LOE: B-NR.
  • Hypertension (New Section): In patients at increased risk, Stage A HF, the optimal blood pressure in those with hypertension should be less than 130/80mmHg.COR: I; LOE: B-R.
  • Patients with Stage C HFrEF and persistent hypertension should be prescribed guideline-directed management and therapy (GDMT) titrated to attain systolic blood pressure less than 130mmHg.  COR: I; LOE: C-EO.
  • Sleep-Disordered Breathing: Recommendations: Patients with NYHA class II-IV HF and suspicion of sleep-disordered breathing or excessive daytime sleepiness, a formal sleep assessment is reasonable.  This recommendation is new and reflects clinical necessity to distinguish obstructive sleep apnea versus central sleep apnea. COR: IIa; LOE: C-LD.
  • In patients with NYHA class II-IV HFrEF and central sleep apnea, adaptive servo-ventilation causes harm. New data demonstrates a signal of harm when adaptive servo-ventilation is used for central sleep apnea.COR: III; Harm; LOE: B-R.
  • In patients with NYHA class II and III HF and iron deficiency (ferritin <100ng/ml or 100 to 300ng/ml, if transferrin saturation in <20%), intravenous iron replacement might be reasonable to improve functional status and quality of life (QoL).  New evidence consistent with therapeutic benefit. COR: IIb; LOE: B-R