Guidelines for Treating Heart Failure

NOTE: The following information is intended to present highlights of the Heart Failure Society of America's (HFSA) heart failure (HF) practice guidelines. For complete information, please visit the HFSA's website at www.heartfailureguideline.org, in particular the Heart Failure Practice Guideline Key Recommendation Slide Set.

The HFSA recommends the following guidelines for determining treatment for patients with HF. These recommendations are based on the strength of evidence gained through randomized controlled trials, cohort and case control studies, and expert opinion.

Prevention is the first line of defense against the onset of heart failure (HF). A careful and thorough clinical assessment and evaluation of risk factors is recommended to prevent the development of HF. Listed below are some of the most common risk factors for HF, with their corresponding goals for treatment:

Physicians with patients who exhibit symptoms of or are at risk for HF have various options for treating or reducing symptoms. The HFSA recommends the following preventative treatment therapies*:

• ACE Inhibitors and Beta Blockers are recommended for prevention of HF (for patients who are at high risk) and for all patients with prior MI.
• ACE inhibitors are recommended for symptomatic and asymptomatic patients with LVEF £ 40%.
• In patients who cannot tolerate ACE Inhibitors due to cough, angiotensin receptor blockers are recommended.
• Beta blockers (carvedilol, bisoprolol, and metoprolol succinate) are recommended for symptomatic and asymptomatic patients with LVEF £ 40%. Beta Blockers are also recommended for patients with a recent decompensation of HF after optimization of volume status and successful discontinuation of IV diuretics and vasoactive agents.
• ACE inhibitor and beta blocker therapy is recommended as standard therapy in elderly patients with HF due to LV systolic dysfunction.
• Aggressive blood pressure monitoring

For those experiencing symptoms (Class II, III or IV HF), the HFSA recommends the following treatment guidelines*:

• Aldosterone antagonist is recommended for patients on standard therapy, including diuretics, who have NYHA class IV HF (or class III, previously class IV) due to LV systolic dysfunction (LVEF £ 35%).
  • AAs are not recommended when: creatinine > 2.5 mg.dl, serum potassium >5.0 mmol/L, or therapy includes other potassium-sparing diuretics
• A combination of Hydralazine and isosorbide dinitrate is recommended as part of standard therapy (in addition to ACE inhibitors and beta blockers) for African Americans with LV systolic dysfunction NYHA III or IV HF or as second-line therapy in NYHA II HF
• Diuretic therapy, especially loop diuretics, are recommended to restore or maintain normal volume status in patients with clinical evidence of fluid overload, generally manifested by congested symptoms or signs of elevated filling pressures.
  • IV administration of diuretics may be necessary.
• Prophylactic ICD placement should be considered in patients with NYHA II-III HF (LVEF £ 30%) and may be considered in those with NYHA II-III HF (LVEF 31-35%).
  • Concomitant placement should be considered in NYHA III-IV patients undergoing implantation of a biventricular pacing device.
• Biventricular pacing therapy should be considered for patients with all of the following: sinus rhythm, a widened QRS interval (³120 ms), severe LV systolic dysfunction (LVEF £ 35% with LV dilation > 5.5 cm), and persistent, moderate to severe HF (NYHA III-IV) despite optimal medical therapy.

Additional HF treatment options are currently under investigation. Click here.

* Source: Heart Failure Society of America 2006 Heart Failure Practice Guideline Key Recommendations