Revised ACC/AHA HF guidelines address aldosterone, device use, quality of life

June 14, 2013

Washington, DC - The just-released 2013 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for heart failure present a strong evidence-based approach that covers the spectrum from screening for the disease, through treatments, to discussing end-of-life care[1].

This is the third full rewrite of the previous guidelines that were issued in 2000, and it reflects the advance in medicine and the growing body of evidence that has become available to guide treatment decisions. The guidelines will be published in the August 27, 2013 issue of the Journal of the American College of Cardiology.

Speaking to heartwire , writing committee cochair Dr Clyde Yancy (Northwestern University, Chicago, IL) highlighted three important changes.

First, the guidelines present a better characterization and understanding of the disease and its natural history. At one end of the care spectrum, the guidelines address screening family members and doing genetic testing in patients with idiopathic cardiomyopathy. At the other end, the guidelines prompt conversations about palliative care.

"It really is important to have this bookend approach to HF, where we think carefully about who gets this disease and why. . . . For those with the disease, [it is important] to have discussions about quality of life, about outcomes, and being courageous enough to have the conversation about palliative care and hospice." The guidelines provide direction for this broad patient management.

Second, the guidelines provide updated treatment strategies. What's new is the earlier use of certain medical therapies such as aldosterone antagonists and the earlier, more precise use of device therapy in heart failure. "We have data now that help us better orchestrate how patients are treated," Yancy said.

The writing committee uses the term "guideline-directed medical therapy" to represent optimal medical therapy (primarily class I). After sifting through more than 900 papers and armed with this strong evidence, the task force was "bold enough to say, here is a one-page algorithm with guideline-recommended [treatment]," such that the practitioner can match the patient's characteristics and come up with a personalized treatment plan that allows the patient to have the best outcome.

Third, "we developed steps that are evidence-based to reduce readmission, to improve the transition of care . . . and we repositioned the performance measures," he said.

Some specific new features are:

  • Earlier use of aldosterone antagonists.

  • Extending cardiac resynchronization therapy (CRT) device use to patients with mild to moderate heart failure.

  • More emphasis on quality of care and adherence to performance measures for heart failure.

  • Updated strategies to prevent heart failure.

  • Updated guidelines for genetic testing.

  • A greater focus on quality of life, patient-centric outcomes, and a shared decision-making strategy in heart failure.

"Our big picture approach was to make it clear that heart failure, classically regarded as a futile disease, now carries a more hopeful outlook. Patients can and should do better with this disease than before, and the exhaustive burden of this disease can be lessened. Patients deserve a chance at best medical therapy for all diseases but especially for heart failure. This guideline statement is a big effort to help make that happen," Yancy and writing committee cochair Dr Mariell Jessup (University of Pennsylvania, Philadelphia) said in a statement.

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