2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults

HomeCirculationVol. 119, No. 142009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUB2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in AdultsA 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 2009 WRITING GROUP TO REVIEW NEW EVIDENCE AND UPDATE THE 2005 GUIDELINE FOR THE MANAGEMENT OF PATIENTS WITH CHRONIC HEART FAILURE WRITING ON BEHALF OF THE 2005 HEART FAILURE WRITING COMMITTEE Mariell Jessup, MD, FACC, FAHA, William T. Abraham, MD, FACC, FAHA, Donald E. Casey, MD, MPH, MBA, Arthur M. Feldman, MD, PhD, FACC, FAHA, Gary S. Francis, MD, FACC, FAHA, Theodore G. Ganiats, MD, Marvin A. Konstam, MD, FACC, Donna M. Mancini, MD, Peter S. Rahko, MD, FACC, FAHA, Marc A. Silver, MD, FACC, FAHA, Lynne Warner Stevenson, MD, FACC, FAHA and Clyde W. Yancy, MD, FACC, FAHA 2009 WRITING GROUP TO REVIEW NEW EVIDENCE AND UPDATE THE 2005 GUIDELINE FOR THE MANAGEMENT OF PATIENTS WITH CHRONIC HEART FAILURE WRITING ON BEHALF OF THE 2005 HEART FAILURE WRITING COMMITTEE Search for more papers by this author , Mariell JessupMariell Jessup Search for more papers by this author , William T. AbrahamWilliam T. Abraham Search for more papers by this author , Donald E. CaseyDonald E. Casey Search for more papers by this author , Arthur M. FeldmanArthur M. Feldman Search for more papers by this author , Gary S. FrancisGary S. Francis Search for more papers by this author , Theodore G. GaniatsTheodore G. Ganiats Search for more papers by this author , Marvin A. KonstamMarvin A. Konstam Search for more papers by this author , Donna M. ManciniDonna M. Mancini Search for more papers by this author , Peter S. RahkoPeter S. Rahko Search for more papers by this author , Marc A. SilverMarc A. Silver Search for more papers by this author , Lynne Warner StevensonLynne Warner Stevenson Search for more papers by this author and Clyde W. YancyClyde W. Yancy Search for more papers by this author Originally published26 Mar 2009https://doi.org/10.1161/CIRCULATIONAHA.109.192064Circulation. 2009;119:1977–2016Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 26, 2009: Previous Version 1 Preamble…19781. Introduction…1980 1.1. Evidence Review…1980 1.2. Organization of Committee and Relationships With Industry…1980 1.3. Review and Approval…1980 1.4. Stages of Heart Failure: Information From the 2005 Guideline…19813. Initial and Serial Clinical Assessment of Patients Presenting With Heart Failure…1981 3.1. Initial Evaluation of Patients…1981 3.1.1. Identification of Patients…1981 3.1.2. Identification of a Structural and Functional Abnormality…1984 3.1.3.2. Laboratory Testing…1985 3.2.3. Laboratory Assessment…1985 3.2.4. Assessment of Prognosis…19864. Therapy…1987 4.3.1. Patients With Reduced Left Ventricular Ejection Fraction…1987 4.3.1.1. General Measures…1987 4.3.1.2.5. Ventricular Arrhythmias and Prevention of Sudden Death…1990 4.3.1.3.3. Hydralazine and Isosorbide Dinitrate…1993 4.3.1.3.4. Cardiac Resynchronization Therapy…1993 4.3.1.5.2. Intermittent Intravenous Positive Inotropic Therapy…1994 4.4. Patients With Refractory End-Stage Heart Failure (Stage D)…1994 4.4.3. Intravenous Peripheral Vasodilators and Positive Inotropic Agents…1996 4.5. The Hospitalized Patient (New Section)…1996 4.5.1. Diagnostic Strategies…1998 4.5.2. Treatment in the Hospital…1999 4.5.2.1. Diuretics: The Patient With Volume Overload…1999 4.5.2.2. Vasodilators…2000 4.5.2.3. Inotropes…2000 4.5.2.4. Other Considerations…2001 4.5.3. The Hospital Discharge…20015. Treatment of Special Populations…20026. Patients With Heart Failure Who Have Concomitant Disorders…2002 6.1.3. Supraventricular Arrhythmias…2002References…2004Appendix 1…2012Appendix 2…2013PreambleA primary challenge in the development of clinical practice guidelines is keeping pace with the stream of new data on which recommendations are based. In an effort to respond more quickly to new evidence, the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Task Force on Practice Guidelines has created a “focused update” process to revise the existing guideline recommendations that are affected by the evolving data or opinion. Prior to the initiation of this focused approach, periodic updates and revisions of existing guidelines required up to 3 years to complete. Now, however, new evidence is reviewed in an ongoing fashion to more efficiently respond to important science and treatment trends that could have a major impact on patient outcomes and quality of care. Evidence is reviewed at least twice a year, and updates will be initiated on an as-needed basis as quickly as possible, while maintaining the rigorous methodology that the ACCF and AHA have developed during their more than 20 years of partnership.These updated guideline recommendations reflect a consensus of expert opinion after a thorough review primarily of late-breaking clinical trials identified through a broad-based vetting process as important to the relevant patient population, as well as of other new data deemed to have an impact on patient care (see Section 1.1., Evidence Review, for details regarding this focused update). It is important to note that this focused update is not intended to represent an update based on a full literature review from the date of the previous guideline publication. Specific criteria/considerations for inclusion of new data include the following: Publication in a peer-reviewed journalLarge randomized, placebo-controlled trial(s)Nonrandomized data deemed important on the basis of results affecting current safety and efficacy assumptionsStrength/weakness of research methodology and findingsLikelihood of additional studies influencing current findingsImpact on current performance measure(s) and/or likelihood of need to develop new performance measure(s)Requests and requirements for review and update from the practice community, key stakeholders, and other sources free of relationships with industry or other potential biasNumber of previous trials showing consistent resultsNeed for consistency with a new guideline or guideline revisionIn analyzing the data and developing updated recommendations and supporting text, the focused update writing group used evidence-based methodologies developed by the ACCF/AHA Task Force on Practice Guidelines, which are described elsewhere.1The schema for class of recommendation and level of evidence is summarized in Table 1, which also illustrates how the grading system provides an estimate of the size of the treatment effect and an estimate of the certainty of the treatment effect. Note that a recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although randomized trials may not be available, there may be a very clear clinical consensus that a particular test or therapy is useful and effective. Both the class of recommendation and level of evidence listed in the focused updates are based on consideration of the evidence reviewed in previous iterations of the guideline as well as the focused update. Of note, the implications of older studies that have informed recommendations but have not been repeated in contemporary settings are carefully considered. Download figureDownload PowerPointTable 1. Applying Classification of Recommendations and Level of Evidence*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.†In 2003, the ACC/AHA Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers’ comprehension of the guidelines and will allow quires at the individual recommendation level.The ACCF/AHA practice guidelines address patient populations (and healthcare providers) residing in North America. As such, drugs that are not currently available in North America are discussed in the text without a specific class of recommendation. For studies performed in large numbers of subjects outside of North America, each writing committee reviews the potential impact of different practice patterns and patient populations on the treatment effect and on the relevance to the ACCF/AHA target population to determine whether the findings should inform a specific recommendation.The ACCF/AHA practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. Thus, there are circumstances in which deviations from these guidelines may be appropriate. Clinical decision making should consider the quality and availability of expertise in the area where care is provided. These guidelines may be used as the basis for regulatory or payer decisions, but the ultimate goals are quality of care and serving the patient’s best interests.Prescribed courses of treatment in accordance with these recommendations are effective only if they are followed by the patient. Because lack of patient adherence may adversely affect treatment outcomes, healthcare providers should make every effort to engage the patient in active participation with prescribed treatment.The ACCF/AHA Task Force on Practice Guidelines makes every effort to avoid actual, potential, or perceived conflict of interest that may arise as a result of industry relationships or personal interests among the writing committee. Specifically, all members of the writing committee, as well as peer reviewers of the document, are asked to disclose all such relationships pertaining to the trials and other evidence under consideration (see Appendixes 1 and 2). Final recommendations were balloted to all writing committee members. Writing committee members with significant (greater than $10 000) relevant relationships with industry were required to recuse themselves from voting on that recommendation. Writing committee members who did not participate are not listed as authors of this focused update.With the exception of the recommendations presented here, the full guideline remains current. Only the recommendations from the affected section(s) of the full guideline are included in this focused update. For easy reference, all recommendations from any section of a guideline affected by a change are presented with notation as to whether they remain current, are new, or have been modified. When evidence affects recommendations in more than 1 set of guidelines, those guidelines are updated concurrently.The recommendations in this focused update are considered current until they are superseded by another focused update or the full-text guidelines are revised. This focused update is published in the April 14, 2009, issues of the Journal of the American College of Cardiology and Circulation as an update to the full-text guideline and is also posted on the ACCF (www.acc.org, www.cardiosource.com) and AHA (my.americanheart.org) Web sites. A revised version of the ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult2 full-text guideline that incorporates the focused update has also been e-published in these issues and is available on the respective Web sites.3 For easy reference, that online-only version denotes sections that have been updated.Sidney C. Smith, Jr, MD, FACC, FAHA Chair, ACCF/AHA Task Force on Practice GuidelinesAlice K. Jacobs, MD, FACC, FAHA Vice-Chair, ACCF/AHA Task Force on Practice Guidelines1. Introduction1.1. Evidence ReviewLate-breaking clinical trials presented at the 2005, 2006, and 2007 annual scientific meetings of the ACCF, AHA, and European Society of Cardiology, as well as selected other data, were reviewed by the standing guideline writing committee along with the parent task force and other experts to identify those trials and other key data that might impact guideline recommendations. On the basis of the criteria/considerations noted earlier, recent trial data and other clinical information were considered important enough to prompt a focused update of the ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult.2 In addition, the guidelines writing committee thought that a new section on the management of the hospitalized patient with heart failure (HF) should be included in this update. A number of recent HF trials reviewed for this update, were, in fact, performed on hospitalized patients, and a number of newer therapies are under development for this population. Moreover, there is increasing government and other third-party payer interest in the prevention of HF hospitalizations, and rehospitalizations. Quality indicators about the process of discharging the HF patient have already been developed, and data about rehospitalizations for HF by hospital have already been made public. Thus, the committee thought that a new section about this important aspect of HF care should be added to this update.When considering the new data for this focused update, the writing group faced the task of weighing evidence from studies enrolling large numbers of subjects outside North America. While noting that practice patterns and the rigor applied to data collection, as well as the genetic makeup of subjects, might influence the observed magnitude of a treatment’s effect, the writing group believed that the data were relevant to formulation of recommendations for the management of HF in North America.Policy on clinical areas not covered by the present focused update can be found in the 2009 Focused Update Incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults.31.2. Organization of Committee and Relationships With IndustryFor this focused update, all members of the 2005 HF writing committee were invited to participate; those who agreed (referred to as the 2009 Focused Update Writing Group) were required to disclose all relationships with industry relevant to the data under consideration.1 Each recommendation required a confidential vote by the writing group members before and after external review of the document. Writing group members who had a significant (greater than $10 000) relationship with industry relevant to a recommendation were required to recuse themselves from voting on that recommendation.1.3. Review and ApprovalThis document was reviewed by 2 external reviewers nominated by the ACCF and 2 external reviewers nominated by the AHA, as well as a reviewer from the ACCF/AHA Task Force on Practice Guidelines, 10 organizational reviewers representing the American College of Chest Physicians, the American College of Physicians, the American Academy of Family Physicians, the Heart Failure Society of America, and the International Society for Heart and Lung Transplantation, and 14 individual content reviewers. All information about reviewers’ relationships with industry was collected and distributed to the writing committee and is published in this document (see Appendix 2 for details).This document was approved for publication by the governing bodies of the ACCF and the AHA and endorsed by the International Society for Heart and Lung Transplantation.1.4. Stages of Heart Failure: Information From the 2005 GuidelineThe HF writing committee previously developed a new approach to the classification of HF,2 one that emphasized both the development and progression of the disease. In doing so, they identified 4 stages involved in the development of the HF syndrome (Figure 1). The first 2 stages (A and B) are clearly not HF but are an attempt to help healthcare providers with the early identification of patients who are at risk for developing HF. Stages A and B patients are best defined as those with risk factors that clearly predispose toward the development of HF. For example, patients with coronary artery disease, hypertension, or diabetes mellitus who do not yet demonstrate impaired left ventricular (LV) function, hypertrophy, or geometric chamber distortion would be considered Stage A, whereas patients who are asymptomatic but demonstrate LV hypertrophy and/or impaired LV function would be designated as Stage B. Stage C then denotes patients with current or past symptoms of HF associated with underlying structural heart disease (the bulk of patients with HF), and Stage D designates patients with truly refractory HF who might be eligible for specialized, advanced treatment strategies, such as mechanical circulatory support, procedures to facilitate fluid removal, continuous inotropic infusions, or cardiac transplantation or other innovative or experimental surgical procedures, or for end-of-life care, such as hospice. Download figureDownload PowerPointFigure 1. Stages in the Development of Heart Failure/Recommended Therapy by Stage. ACEI indicates angiotensin-converting enzyme inhibitors; ARB, angiotensin II receptor blocker; EF, ejection fraction; FHx CM, family history of cardiomyopathy; HF, heart failure; LVH, left ventricular hypertrophy; and MI, myocardial infarction.3. Initial and Serial Clinical Assessment of Patients Presenting With Heart FailureThe changes in this section are made to clarify the role of functional assessment of the HF patient, beyond the New York Heart Association (NYHA) classification, and to expand on the use of B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing within the context of the overall evaluation of the patient (Table 2). Table 2. Updates to Section 3. Initial and Serial Clinical Assessment of Patients Presenting With Heart Failure2005 Guideline Recommendations2009 Focused Update RecommendationsComments3. Recommendations for the Initial Clinical Assessment of Patients Presenting With Heart FailureClass IA thorough history and physical examination should be obtained/performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF. (Level of Evidence: C)1. A thorough history and physical examination should be obtained/performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of HF. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.A careful history of current and past use of alcohol, illicit drugs, current or past standard or “alternative therapies,” and chemotherapy drugs should be obtained from patients presenting with HF. (Level of Evidence: C)2. A careful history of current and past use of alcohol, illicit drugs, current or past standard or “alternative therapies,” and chemotherapy drugs should be obtained from patients presenting with HF. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.In patients presenting with HF, initial assessment should be made of the patient’s ability to perform routine and desired activities of daily living. (Level of Evidence: C)3. In patients presenting with HF, initial assessment should be made of the patient’s ability to perform routine and desired activities of daily living. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Initial examination of patients presenting with HF should include assessment of the patient’s volume status, orthostatic blood pressure changes, measurement of weight and height, and calculation of body mass index. (Level of Evidence: C)4. Initial examination of patients presenting with HF should include assessment of the patient’s volume status, orthostatic blood pressure changes, measurement of weight and height, and calculation of body mass index. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Initial laboratory evaluation of patients presenting with HF should include complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, fasting blood glucose (glycohemoglobin), lipid profile, liver function tests, and thyroid-stimulating hormone. (Level of Evidence: C)5. Initial laboratory evaluation of patients presenting with HF should include complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, fasting blood glucose (glycohemoglobin), lipid profile, liver function tests, and thyroid-stimulating hormone. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Twelve-lead electrocardiogram and chest radiograph (posterior to anterior [PA] and lateral) should be performed initially in all patients presenting with HF. (Level of Evidence: C)6. Twelve-lead electrocardiogram and chest radiograph (PA and lateral) should be performed initially in all patients presenting with HF. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Two-dimensional echocardiography with Doppler should be performed during initial evaluation of patients presenting with HF to assess left ventricular ejection fraction (LVEF), LV size, wall thickness, and valve function. Radionuclide ventriculography can be performed to assess LVEF and volumes. (Level of Evidence: C)7. Two-dimensional echocardiography with Doppler should be performed during initial evaluation of patients presenting with HF to assess LVEF, left ventricular size, wall thickness, and valve function. Radionuclide ventriculography can be performed to assess LVEF and volumes. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Coronary arteriography should be performed in patients presenting with HF who have angina or significant ischemia unless the patient is not eligible for revascularization of any kind. (Level of Evidence: B)8. Coronary arteriography should be performed in patients presenting with HF who have angina or significant ischemia unless the patient is not eligible for revascularization of any kind.4–8(Level of Evidence: B)2005 recommendation remains current in the 2009 update.Class IIaCoronary arteriography is reasonable for patients presenting with HF who have chest pain that may or may not be of cardiac origin who have not had evaluation of their coronary anatomy and who have no contraindications to coronary revascularization. (Level of Evidence: C)1. Coronary arteriography is reasonable for patients presenting with HF who have chest pain that may or may not be of cardiac origin who have not had evaluation of their coronary anatomy and who have no contraindications to coronary revascularization. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Coronary arteriography is reasonable for patients presenting with HF who have known or suspected coronary artery disease but who do not have angina unless the patient is not eligible for revascularization of any kind. (Level of Evidence: C)2. Coronary arteriography is reasonable for patients presenting with HF who have known or suspected coronary artery disease but who do not have angina unless the patient is not eligible for revascularization of any kind. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Noninvasive imaging to detect myocardial ischemia and viability is reasonable in patients presenting with HF who have known coronary artery disease and no angina unless the patient is not eligible for revascularization of any kind. (Level of Evidence: B)3. Noninvasive imaging to detect myocardial ischemia and viability is reasonable in patients presenting with HF who have known coronary artery disease and no angina unless the patient is not eligible for revascularization of any kind.9(Level of Evidence: B)2005 recommendation remains current in the 2009 update.(continued)Table 2. Continued2005 Guideline Recommendations2009 Focused Update RecommendationsCommentsClass IIa (Continued)Maximal exercise testing with or without measurement of respiratory gas exchange and/or blood oxygen saturation is reasonable in patients presenting with HF to help determine whether HF is the cause of exercise limitation when the contribution of HF is uncertain. (Level of Evidence: C)4. Maximal exercise testing with or without measurement of respiratory gas exchange and/or blood oxygen saturation is reasonable in patients presenting with HF to help determine whether HF is the cause of exercise limitation when the contribution of HF is uncertain. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Maximal exercise testing with measurement of respiratory gas exchange is reasonable to identify high-risk patients presenting with HF who are candidates for cardiac transplantation or other advanced treatments. (Level of Evidence: B)5. Maximal exercise testing with measurement of respiratory gas exchange is reasonable to identify high-risk patients presenting with HF who are candidates for cardiac transplantation or other advanced treatments.10–12(Level of Evidence: B)2005 recommendation remains current in the 2009 update.Screening for hemochromatosis, sleep-disturbed breathing, or human immunodeficiency virus is reasonable in selected patients who present with HF. (Level of Evidence: C)6. Screening for hemochromatosis, sleep-disturbed breathing, or human immunodeficiency virus is reasonable in selected patients who present with HF. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Diagnostic tests for rheumatologic diseases, amyloidosis, or pheochromocytoma are reasonable in patients presenting with HF in whom there is a clinical suspicion of these diseases. (Level of Evidence: C)7. Diagnostic tests for rheumatologic diseases, amyloidosis, or pheochromocytoma are reasonable in patients presenting with HF in whom there is a clinical suspicion of these diseases. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Endomyocardial biopsy can be useful in patients presenting with HF when a specific diagnosis is suspected that would influence therapy. (Level of Evidence: C)8. Endomyocardial biopsy can be useful in patients presenting with HF when a specific diagnosis is suspected that would influence therapy.13(Level of Evidence: C)2005 recommendation remains current in the 2009 update.Measurement of BNP can be useful in the evaluation of patients presenting in the urgent care setting in whom the clinical diagnosis of HF is uncertain. (Level of Evidence: A)9. Measurement of natriuretic peptides (BNP and NT-proBNP) can be useful in the evaluation of patients presenting in the urgent care setting in whom the clinical diagnosis of HF is uncertain. Measurement of natriuretic peptides (BNP and NT-proBNP) can be useful in risk stratification.14–21(Level of Evidence: A)Modified recommendation (added a caveat on natriuretic peptides and their role as part of total evaluation, in both diastolic and systolic dysfunction).Class IIbNoninvasive imaging may be considered to define the likelihood of coronary artery disease in patients with HF and LV dysfunction. (Level of Evidence: C)1. Noninvasive imaging may be considered to define the likelihood of coronary artery disease in patients with HF and LV dysfunction. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Holter monitoring might be considered in patients presenting with HF who have a history of myocardial infarction (MI) and are being considered for electrophysiologic study to document ventricular tachycardia (VT) inducibility. (Level of Evidence: C)2. Holter monitoring might be considered in patients presenting with HF who have a history of MI and are being considered for electrophysiologic study to document VT inducibility. (Level of Evidence: C)2005 recommendation remains current in the 2009 update.Class IIIEndomyocardial biopsy should not be performed in the routine evaluation of patients with HF. (Level of Evidence: C)1. Endomyocardial biopsy should not be performed in the routine evaluation of patients with HF.13(Level of Evidence: C)2005 recommendation remains current in the 200