The American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Failure Society of America (HFSA), has jointly issued an update of the 2013 ACCF/AHA guidelines for the management of heart failure (HF). The update is the second part of the guideline; the first part was issued in May 2016. The new guidelines focus on new tests for HF prevention and feature a new section on hypertension. Highlights and recommendations include:
- Natriuretic peptide biomarker screening and early intervention may prevent HF.
- During a HF hospitalization, a predischarge natriuretic peptide level can be useful to establish a postdischarge prognosis.
- In patients at increased risk, stage A HF, the optimal blood pressure in those with hypertension should be <130/80 mm Hg.
- In patients with NYHA class II and III HF and iron deficiency (ferritin <100 ng/mL or 100 to 300 ng/mL if transferrin saturation is <20%), intravenous iron replacement might be reasonable to improve functional status and QoL.
- In appropriately selected patients with HFEF (with EF ≥45%, elevated BNP levels or HF admission within 1 year, estimated glomerular filtration rate >30 mL/min, creatinine <2.5 mg/dL, potassium <5.0 mEq/L), aldosterone receptor antagonists might be considered to decrease hospitalizations.
The guidelines also included recommendations on pharmacotherapies for HF and for sleep disordered breathing.
Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure. [Published online ahead of print April 28, 2017]. Circulation. doi:10.1161/CIR.0000000000000509.
The recommendation for prevention of heart failure in at-risk patients with the use of BNP screening is interesting and represents a radical shift in approaches to HF. The recommendation, carefully worded as “can be helpful,” is based primarily on 1 study, and is not a blanket recommendation for screening patients with BNP. The recommendation to consider an aldosterone antagonist in patients with HFpEF is new, based on a single trial that showed some benefit (HR, 0.89) that missed statistical significance on its main composite endpoint but showed a decrease in hospitalization, and may be worth implementing, given the paucity of evidence-based treatments for HFpEF. The recommendation for aggressive treatment of anemia is new, as anemia is associated with decreased exercise capacity and quality of life, and improvement of anemia improves both of these characteristics. The recommendation to use IV iron rather than oral iron supplementation exists because that is what was used in the studies. There was no evidence that oral iron does not work just as well in patients that respond to IV iron. The recommendation for a systolic BP target of less than 130 is based on data from the SPRINT trial, which showed better outcomes in patients with a systolic target of <120 mmHg, and the recognition that office BPs as taken are about 10 mmHg higher than the BPs obtained in SPRINT. —Neil Skolnik, MD