SEATTLE — The Heart Failure Society of America introduced at its annual meeting its 2006 Comprehensive Heart Failure Practice Guidelines, which updates its original 1999 guidelines.
“There wasn't much data available then. It was a good start, but this is a completely different document,” said Dr. JoAnn Lindenfeld, current chair of the heart failure practice guideline committee and director of heart transplantation at the University of Colorado Health Sciences Center, Denver.
The Heart Failure Society of America (HFSA) guidelines are more comprehensive than two other sets of heart failure guidelines put out separately in 2005 by the European Society of Cardiology (ESC) and jointly by the American Heart Association and American College of Cardiology (AHA/ACC), she said.
The AHA/ACC recommendations don't address acute heart failure, and the ESC created separate sets of guidelines for acute and chronic heart failure. The HFSA guidelines include both.
“I think the ESC guidelines go further in [discussion of] subpopulations,” Dr. Kirkwood F. Adams Jr. commented in a discussion session on the HFSA guidelines. “Heart failure [encompasses] about 18 different populations. I think as people look back 100 years from now, they'll be perhaps laughing that we had something called heart failure guidelines when really there are so many different patient varieties.”
One of the values of the HFSA's comprehensive approach is that the guidelines focus attention on the enormous public health problem that heart failure presents, causing more than 1 million U.S. hospitalizations per year, added Dr. Adams, who cochaired the guidelines committee with Dr. Lindenfeld and is director of the heart failure program at the University of North Carolina, Chapel Hill. “It's good to push recognition” of the problem among both specialists and primary care physicians, who manage 80% of patients with heart failure.
The HFSA guidelines comprise 16 sections that include acute or chronic heart failure, disease management, heart failure in special populations, hypertension in heart failure, heart failure with preserved ejection fraction, and more. The recommendations come in four strengths:
▸ Is recommended—part of routine care, with very few exceptions.
▸ Should be considered—the majority of patients should receive the intervention.
▸ May be considered—individualize the therapy to the patient.
▸ Is not recommended—don't use the intervention.
The guidelines also present the level of evidence for recommendations, following routine models for rating evidence with one exception: One randomized trial could constitute the highest level of evidence (A). “That's controversial,” Dr. Adams said.
In some categories, recommendations of the highest level are not based on the highest level of evidence. Although the guidelines on acute decompensated heart failure include many interventions that are “recommended,” none of these are based on level A evidence, for example, Dr. Lindenfeld said.
“This points out how far we have to go in the data and studies of acute decompensated heart failure,” she said.
The HFSA committee elected not to present majority and minority opinions on its recommendations, as some other guidelines do. “I think majority/minority opinions are useless. You go to the guidelines to get a recommendation,” Dr. Adams said.
The HFSA committee plans to update the guidelines yearly. Topics not covered in the current guidelines that may be included in future versions include genetic screening and testing of patients with heart failure, the timing of altering diuretic therapy, and more guidance on implantable devices.
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