Guideline Management
Of
Heart Failure
2013 ACC/AHA Updated Heart Failure
Guidelines
Dawn Lombardo DO, MS
Associate Professor Medicine
University of California, Irvine
Medical Director Heart Failure Program
and Echocardiography Lab
AHA 2009
Population
Group
Total
population
Heart Failure
Prevalence
5,000,000
Incidence
670,000
Mortality
57,218
Hospital
Discharges
1,093,000
Cost
$29.6
billion
Despite advances in HF treatment the # of HF deaths
continues to ↑:
↑’ing age of the population
advanced cardiotherapeutic interventions
HF is a “condition of the elderly”
≈ 80% ADHF hospitalizations are ≥ 65 y/o
Most common hospital D/C DRG
↑’st Medicare $ spent
www.acc.org/clinical/guidelines/failure//index.pdf
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
1
Epidemic Proportions of HF
US figures in millions/year
100
AHA 2009
37.2
Billion
$
50
~15
10
~6.5
~5
5
1.0
1
0.5
0.3
0
Deaths Hosp. Hosp. Office
Adm. Days Visits
$
Susceptible
Symptomatic
Asymptomatic
First DX
Lindenfeld J, et al. HFSA 2010 Comprehensive
www.acc.org/clinical/guidelines/failure//index.pdf
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Definition of Heart Failure
Classification
I. Heart Failure with
Reduced Ejection Fraction
(HFrEF)
Ejection
Fraction
≤40%
Description
Also referred to as systolic HF. Randomized clinical trials have
mainly enrolled patients with HFrEF and it is only in these patients
that efficacious therapies have been demonstrated to date.
≥50%
Also referred to as diastolic HF. Several different criteria have been
used to further define HFpEF. The diagnosis of HFpEF is
challenging because it is largely one of excluding other potential
noncardiac causes of symptoms suggestive of HF. To date,
efficacious therapies have not been identified.
a. HFpEF, Borderline
41% to 49%
These patients fall into a borderline or intermediate group. Their
characteristics, treatment patterns, and outcomes appear similar to
those of patient with HFpEF.
b. HFpEF, Improved
>40%
It has been recognized that a subset of patients with HFpEF
previously had HFrEF. These patients with improvement or recovery
in EF may be clinically distinct from those with persistently
preserved or reduced EF. Further research is needed to better
characterize these patients.
II. Heart Failure with
Preserved Ejection
Fraction (HFpEF)
1 of 2
HFSA 2010 Practice Guideline
Definition of Heart Failure
A syndrome caused by cardiac dysfunction
 Leading to neurohormonal & circulatory abnormalities
and characteristic symptoms:
 Fluid retention
 Shortness of breath
 Fatigue, especially on exertion
 Left untreated  usually progressive.
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
2 of 2
HFSA 2010 Practice Guideline
Definition of Heart Failure
Although HF is progressive and often fatal, patients
can be stabilized and myocardial dysfunction and
remodeling may improve, either spontaneously or
as a consequence of therapy.
In physiological terms, HF is a syndrome
characterized by:
 Elevated cardiac filling pressure
OR
 Inadequate peripheral oxygen delivery, at rest or
during stress, caused by cardiac dysfunction.
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline
HF with Preserved LVEF
"HF with Preserved EF = HFPEF"
 Clinical syndrome characterized by S & S of HFpEF.
 Most commonly associated with a non-dilated LV
chamber.
 May be the result of HTN, valvular disease, CAD, DM
or other causes.
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Classification of HF
ACC/AHA Guidelines 2009
D
Refractory
C
Prior, current symptoms
B
Structural heart disease
LVH, MI, low LVEF, dilatation, valvular disease
A
High-risk patients HF Prevention
Hypertension, diabetes, coronary disease, family history, cardiotoxic drugs
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
ACC-AHA Guidelines 2009
Pre-HF
Asymptomatic Symptomatic Advanced
A
NYHA Functional Class
B
C
I
II, III
D
IV
Remodeling
Reverse Remodeling
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Classification of Heart Failure
A
B
C
ACCF/AHA Stages of HF
At high risk for HF but without structural
heart disease or symptoms of HF.
Structural heart disease but without signs
or symptoms of HF.
Structural heart disease with prior or
current symptoms of HF.
NYHA Functional Classification
None
I
I
II
III
IV
D
Refractory HF requiring specialized
interventions.
No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
No limitation of physical activity.
Ordinary physical activity does not cause
symptoms of HF.
Slight limitation of physical activity.
Comfortable at rest, but ordinary physical
activity results in symptoms of HF.
Marked limitation of physical activity.
Comfortable at rest, but less than ordinary
activity causes symptoms of HF.
Unable to carry on any physical activity
without symptoms of HF, or symptoms of
HF at rest.
Treatment Objectives
Decreased symptoms
Decreased mortality
Increased exercise capacity
Increased quality of life
Decreased neurohormonal
changes/remodeling
www.acc.org/clinical/guidelines/failure//index.pdf
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Stages, Phenotypes and Treatment of HF
At Risk for Heart Failure
Heart Failure
STAGE A
STAGE B
STAGE C
At high risk for HF but
without structural heart
disease or symptoms of HF
Structural heart disease
but without signs or
symptoms of HF
Structural heart disease
with prior or current
symptoms of HF
e.g., Patients with:
· HTN
· Atherosclerotic disease
· DM
· Obesity
· Metabolic syndrome
or
Patients
· Using cardiotoxins
· With family history of
cardiomyopathy
Structural heart
disease
e.g., Patients with:
· Previous MI
· LV remodeling including
LVH and low EF
· Asymptomatic valvular
disease
Development of
symptoms of HF
e.g., Patients with:
· Known structural heart disease and
· HF signs and symptoms
HFpEF
THERAPY
Goals
· Heart healthy lifestyle
· Prevent vascular,
coronary disease
· Prevent LV structural
abnormalities
Drugs
· ACEI or ARB in
appropriate patients for
vascular disease or DM
· Statins as appropriate
THERAPY
Goals
· Prevent HF symptoms
· Prevent further cardiac
remodeling
Drugs
· ACEI or ARB as
appropriate
· Beta blockers as
appropriate
In selected patients
· ICD
· Revascularization or
valvular surgery as
appropriate
STAGE D
Refractory HF
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Prevent hospitalization
· Prevent mortality
Strategies
· Identification of comorbidities
Treatment
· Diuresis to relieve symptoms
of congestion
· Follow guideline driven
indications for comorbidities,
e.g., HTN, AF, CAD, DM
· Revascularization or valvular
surgery as appropriate
Refractory
symptoms of HF
at rest, despite
GDMT
e.g., Patients with:
· Marked HF symptoms at
rest
· Recurrent hospitalizations
despite GDMT
HFrEF
THERAPY
Goals
· Control symptoms
· Patient education
· Prevent hospitalization
· Prevent mortality
Drugs for routine use
· Diuretics for fluid retention
· ACEI or ARB
· Beta blockers
· Aldosterone antagonists
Drugs for use in selected patients
· Hydralazine/isosorbide dinitrate
· ACEI and ARB
· Digoxin
In selected patients
· CRT
· ICD
· Revascularization or valvular
surgery as appropriate
THERAPY
Goals
· Control symptoms
· Improve HRQOL
· Reduce hospital
readmissions
· Establish patient’s endof-life goals
Options
· Advanced care
measures
· Heart transplant
· Chronic inotropes
· Temporary or permanent
MCS
· Experimental surgery or
drugs
· Palliative care and
hospice
· ICD deactivation
Initial and Serial Evaluation of the HF
Patient
History and Physical
Examination
History and Physical Examination
I IIa IIb III
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.
I IIa IIb III
In patients with idiopathic DCM, a 3-generational family
history should be obtained to aid in establishing the
diagnosis of familial DCM.
I IIa IIb III
Volume status and vital signs should be assessed at
each patient encounter. This includes serial assessment
of weight, as well as estimates of jugular venous
pressure and the presence of peripheral edema or
orthopnea.
Initial and Serial Evaluation of the HF
Patient
Risk Scoring
Risk Scoring
I IIa IIb III
Validated multivariable risk scores can be
useful to estimate subsequent risk of mortality
in ambulatory or hospitalized patients with HF.
Risk Scores to Predict Outcomes in HF
Risk Score
Reference (from full-text guideline)/Link
Chronic HF
All patients with chronic HF
Seattle Heart Failure Model
(204) / http://SeattleHeartFailureModel.org
Heart Failure Survival Score
(200) / http://handheld.softpedia.com/get/Health/Calculator/HFSS-Calc37354.shtml
CHARM Risk Score
CORONA Risk Score
Specific to chronic HFpEF
I-PRESERVE Score
(207)
(208)
(202)
Acutely Decompensated HF
ADHERE Classification and Regression
Tree (CART) Model
American Heart Association Get With the
Guidelines Score
(201)
EFFECT Risk Score
(203) / http://www.ccort.ca/Research/CHFRiskModel.aspx
ESCAPE Risk Model and Discharge Score
(215)
OPTIMIZE HF Risk-Prediction Nomogram
(216)
(206) /
http://www.heart.org/HEARTORG/HealthcareProfessional/GetWithTheGuidel
inesHFStroke/GetWithTheGuidelinesHeartFailureHomePage/Get-With-TheGuidelines-Heart-Failure-Home- %20Page_UCM_306087_SubHomePage.jsp
Initial and Serial Evaluation of the HF
Patient
Biomarkers
Ambulatory/Outpatient
Ambulatory/Outpatient
I IIa IIb III
In ambulatory patients with dyspnea, measurement of
BNP or N-terminal pro-B-type natriuretic peptide (NTproBNP) is useful to support clinical decision making
regarding the diagnosis of HF, especially in the setting of
clinical uncertainty.
I IIa IIb III
Measurement of BNP or NT-proBNP is useful for
establishing prognosis or disease severity in chronic HF.
Ambulatory/Outpatient (cont.)
I IIa IIb III
BNP- or NT-proBNP guided HF therapy can be useful to
achieve optimal dosing of GDMT in select clinically
euvolemic patients followed in a well-structured HF
disease management program.
I IIa IIb III
The usefulness of serial measurement of BNP or NTproBNP to reduce hospitalization or mortality in patients
with HF is not well established.
I IIa IIb III
Measurement of other clinically available tests such as
biomarkers of myocardial injury or fibrosis may be
considered for additive risk stratification in patients with
chronic HF.
Initial and Serial Evaluation of the HF
Patient
Biomarkers
Hospitalized/Acute
Hospitalized/Acute
I IIa IIb III
Measurement of BNP or NT-proBNP is useful to support
clinical judgment for the diagnosis of acutely
decompensated HF, especially in the setting of
uncertainty for the diagnosis.
I IIa IIb III
Measurement of BNP or NT-proBNP and/or cardiac
troponin is useful for establishing prognosis or disease
severity in acutely decompensated HF.
Hospitalized/Acute (cont.)
I IIa IIb III
The usefulness of BNP- or NT-proBNP guided therapy
for acutely decompensated HF is not well-established.
I IIa IIb III
Measurement of other clinically available tests such as
biomarkers of myocardial injury or fibrosis may be
considered for additive risk stratification in patients with
acutely decompensated HF.
Causes for Elevated Natriuretic
Peptide Levels
Cardiac
· Heart failure, including RV
syndromes
· Acute coronary syndrome
· Heart muscle disease, including
LVH
· Valvular heart disease
· Pericardial disease
· Atrial fibrillation
· Myocarditis
· Cardiac surgery
· Cardioversion
Noncardiac
· Advancing age
· Anemia
· Renal failure
· Pulmonary causes: obstructive
sleep apnea, severe pneumonia,
pulmonary hypertension
· Critical illness
· Bacterial sepsis
· Severe burns
· Toxic-metabolic insults, including
cancer chemotherapy and
envenomation
Recommendations for Biomarkers in HF
Biomarker, Application
Setting
COR
LOE
Diagnosis or exclusion of HF
Ambulatory,
Acute
I
A
Prognosis of HF
Ambulatory,
Acute
I
A
Ambulatory
IIa
B
Acute
IIb
C
Acute,
Ambulatory
I
A
IIb
B
IIb
A
Natriuretic peptides
Achieve GDMT
Guidance of acutely decompensated
HF therapy
Biomarkers of myocardial injury
Additive risk stratification
Biomarkers of myocardial fibrosis
Ambulatory
Additive risk stratification
Acute
Initial and Serial Evaluation of the HF
Patient
Noninvasive Cardiac Imaging
Recommendations for Noninvasive Imaging
Recommendation
Patients with suspected, acute, or new-onset HF should undergo a chest xray
A 2-dimensional echocardiogram with Doppler should be performed for
initial evaluation of HF
Repeat measurement of EF is useful in patients with HF who have had a
significant change in clinical status or received treatment that might
affect cardiac function, or for consideration of device therapy
Noninvasive imaging to detect myocardial ischemia and viability is
reasonable in HF and CAD
Viability assessment is reasonable before revascularization in HF patients
with CAD
Radionuclide ventriculography or MRI can be useful to assess LVEF and
volume
MRI is reasonable when assessing myocardial infiltration or scar
Routine repeat measurement of LV function assessment should not be
performed
COR
LOE
I
C
I
C
I
C
IIa
C
IIa
B
IIa
C
IIa
B
III: No
Benefit
B
Initial and Serial Evaluation of the HF
Patient
Invasive Evaluation
Recommendations for Invasive Evaluation
Recommendation
COR
LOE
I
C
Invasive hemodynamic monitoring can be useful for carefully selected
patients with acute HF with persistent symptoms and/or when hemodynamics
are uncertain
IIa
C
When coronary ischemia may be contributing to HF, coronary arteriography
is reasonable
IIa
C
Endomyocardial biopsy can be useful in patients with HF when a specific
diagnosis is suspected that would influence therapy
IIa
C
Routine use of invasive hemodynamic monitoring is not recommended in
normotensive patients with acute HF
III: No
Benefit
B
III: Harm
C
Monitoring with a pulmonary artery catheter should be performed in
patients with respiratory distress or impaired systemic perfusion when
clinical assessment is inadequate
Endomyocardial biopsy should not be performed in the routine evaluation of
HF
Guideline for HF
Treatment of Stages A to D
Treatment of Stages A to D
Stage A
HFSA 2010 Practice Guideline (3.1)
Heart Failure Prevention
Stage A = “At Risk Population”
A careful and thorough clinical
assessment, with appropriate
investigation for known or potential risk
factors, is recommended in an effort to
prevent development of LV remodeling,
cardiac dysfunction, and HF.
Strength of Evidence = A
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Stage A
I IIa IIb III
I IIa IIb III
Hypertension and lipid disorders should be controlled in
accordance with contemporary guidelines to lower the risk
of HF.
Other conditions that may lead to or contribute to HF, such
as obesity, diabetes mellitus, tobacco use, and known
cardiotoxic agents, should be controlled or avoided.
HFSA 2010 Practice Guideline (3.2)
HF Risk Factor Treatment Goals
Risk Factor
Goal
Hypertension
Generally < 130/80
Diabetes
See ADA guidelines1
Hyperlipidemia
See NCEP guidelines2
Inactivity
20-30 min. aerobic 3-5 x wk.
Obesity
Weight reduction < 30 BMI
Alcohol
Men ≤ 2 drinks/day, women ≤ 1
Smoking
Cessation
Dietary Sodium
Maximum 2-3 g/day
1Diabetes
2JAMA
Adapted from:
Care 2006; 29: S4-S42
2001; 285:2486-97
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Alcohol Equivalents
One
drink
=
12-14 g alcohol =
1.5 oz 80-proof
spirits
=
12 oz beer
=
5 oz wine
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Sodium Equivalents
Salt
Sodium Chloride
Sodium
¼ tsp
1550 mg
600 mg
½ tsp
3100 mg
1200 mg
¾ tsp
4650 mg
1800 mg
1 tsp
6100 mg
2400 mg
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Treating Hypertension to Prevent HF
Aggressive blood
pressure control:
Decreases
risk of
new HF
by ~ 50%
in DM2
Lancet 1991;338:1281-5 (STOP-Hypertension
JAMA 1997;278:212-6 (SHEP)
UKPDS Group. UKPDS 38. BMJ 1998;317:703-713
Aggressive BP control
in patients with prior MI:
Decreases
risk of
new HF
by ~ 80%
HFSA 2010 Practice Guideline (3.3-3.4)
Prevention—ACEI and Beta Blockers
ACE inhibitors are recommended for prevention of HF in
patients at high risk for this syndrome, including those
with:
 Coronary artery disease
 Peripheral vascular disease
 Stroke
 Diabetes and another major risk factor
Strength of Evidence = A
ACE inhibitors and beta blockers are recommended for all
patients with prior MI.
Strength of Evidence = A
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Management of Patients with Known
Atherosclerotic Disease But No HF
Treatment with ACE
inhibitors decreases
the risk of CV death,
MI, stroke, or cardiac
arrest.
16
14
12
% MI, 10
Stroke, 8
CV Death 6
4
2
0
Ramipril
22% rel. risk red. p < .001
0
1
2
3
4
Years
15
EUROPA
12
NEJM 2000;342:145-53 (HOPE)
Lancet 2003;362:782-8 (EUROPA)
Placebo
HOPE
Placebo
% MI,
CV Death, 9
Cardiac 6
Arrest
Perindopril
3
20% rel. risk red. p = .0003
0
0
1
2
3
Years
4
5
Treatment of Stages A to D
Stage B
Recommendations for Treatment of Stage B HF
Recommendations
In patients with a history of MI and reduced EF, ACE inhibitors or
ARBs should be used to prevent HF
In patients with MI and reduced EF, evidence-based beta blockers
should be used to prevent HF
In patients with MI, statins should be used to prevent HF
Blood pressure should be controlled to prevent symptomatic HF
ACE inhibitors should be used in all patients with a reduced EF to
prevent HF
Beta blockers should be used in all patients with a reduced EF to
prevent HF
An ICD is reasonable in patients with asymptomatic ischemic
cardiomyopathy who are at least 40 d post-MI, have an LVEF ≤30%,
and on GDMT
Nondihydropyridine calcium channel blockers may be harmful in
patients with low LVEF
COR
LOE
I
A
I
B
I
A
I
A
I
A
I
C
IIa
B
III: Harm
C
Treatment of Post-MI Patients with
Asymptomatic LV Dysfunction (LVEF ≤ 40%)
SAVE Study
0.3
Mortality
Rate
 All-cause mortality ↓19%
Placebo
0.2
Captopril
 CV mortality ↓21%
0.1
 HF development ↓37%
 Recurrent MI ↓25%
19% rel. risk reduction
p = 0.019
0
0
0.5
1
1.5
2
2.5
3
3.5
4
Years
Pfeffer et al. NEJM 1992;327:669-77
ACE Inhibitors in Heart Failure:
From Asymptomatic LVD to Severe HF
SOLVD Prevention
(Asymptomatic LVD)
CONSENSUS
(Severe Heart Failure)
20%
death or HF hosp.
40%
mortality at 6 mos.
29%
death or new HF
31%
mortality at 1 year
27%
mortality at end of
study
SOLVD Treatment
(Chronic Heart Failure)
16%
mortality

No difference in incidence
of sudden cardiac death
SOLVD Investigators. N Engl J Med 1992;327:685-91
SOLVD Investigators. N Engl J Med 1991;325:293-302
CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35
The Additional Value of Beta
Blockers Post-MI: CAPRICORN
Carvedilol in post-MI pts, LVEF ≤ 40% on EBT:
revascularization, anticoagulants, ASA, and ACEI:
 All-cause mortality reduced (HR=0.77; p=0.03)
 CV mortality reduced (HR=0.75; p=.024)
 Recurrent non-fatal MIs reduced (HR=.59; p =.014)
Dargie HJ. Lancet 2001;357:1385-90
Treatment of Stages A to D
Pharmacological Treatment for
Stage C HFrEF
Pharmacologic Treatment for Stage C HFrEF
HFrEF Stage C
NYHA Class I – IV
Treatment:
Class I, LOE A
ACEI or ARB AND
Beta Blocker
For all volume overload,
NYHA class II-IV patients
For persistently symptomatic
African Americans,
NYHA class III-IV
For NYHA class II-IV patients.
Provided estimated creatinine
>30 mL/min and K+ <5.0 mEq/dL
Add
Add
Add
Class I, LOE C
Loop Diuretics
Class I, LOE A
Hydral-Nitrates
Class I, LOE A
Aldosterone
Antagonist
Drugs Commonly Used for HFrEF
(Stage C HF)
Drug
ACE Inhibitors
Captopril
Enalapril
Fosinopril
Lisinopril
Perindopril
Quinapril
Ramipril
Trandolapril
ARBs
Candesartan
Losartan
Valsartan
Aldosterone Antagonists
Spironolactone
Eplerenone
Initial Daily Dose(s)
Maximum Doses(s)
Mean Doses Achieved in
Clinical Trials
6.25 mg 3 times
2.5 mg twice
5 to 10 mg once
2.5 to 5 mg once
2 mg once
5 mg twice
1.25 to 2.5 mg once
1 mg once
50 mg 3 times
10 to 20 mg twice
40 mg once
20 to 40 mg once
8 to 16 mg once
20 mg twice
10 mg once
4 mg once
122.7 mg/d (421)
16.6 mg/d (412)
--------32.5 to 35.0 mg/d (444)
---------------------------------
4 to 8 mg once
25 to 50 mg once
20 to 40 mg twice
32 mg once
50 to 150 mg once
160 mg twice
24 mg/d (419)
129 mg/d (420)
254 mg/d (109)
12.5 to 25 mg once
25 mg once
25 mg once or twice
50 mg once
26 mg/d (424)
42.6 mg/d (445)
Drugs Commonly Used for HFrEF
(Stage C HF) (cont.)
Drug
Initial Daily Dose(s)
Beta Blockers
Bisoprolol
1.25 mg once
Carvedilol
3.125 mg twice
Carvedilol CR
10 mg once
Metoprolol succinate
extended release
12.5 to 25 mg once
(metoprolol CR/XL)
Hydralazine & Isosorbide Dinitrate
37.5 mg hydralazine/
Fixed dose combination
20 mg isosorbide
(423)
dinitrate 3 times daily
Hydralazine and
Hydralazine: 25 to 50
isosorbide dinitrate (448)
mg, 3 or 4 times daily
and isorsorbide
dinitrate:
20 to 30 mg
3 or 4 times daily
Maximum Doses(s)
Mean Doses Achieved in
Clinical Trials
10 mg once
50 mg twice
80 mg once
8.6 mg/d (118)
37 mg/d (446)
---------
200 mg once
159 mg/d (447)
75 mg hydralazine/
40 mg isosorbide
dinitrate 3 times daily
Hydralazine: 300 mg
daily in divided doses
and isosorbide dinitrate
120 mg daily in
divided doses
~175 mg hydralazine/90 mg
isosorbide dinitrate daily
---------
Medical Therapy for Stage C HFrEF:
Magnitude of Benefit Demonstrated in RCTs
GDMT
ACE inhibitor or
ARB
Beta blocker
Aldosterone
antagonist
Hydralazine/nitrate
(Standardized to 36 mo)
RR Reduction
in HF
Hospitalizations
17%
26
31%
34%
9
41%
30%
6
35%
43%
7
33%
RR Reduction
in Mortality
NNT for Mortality
Reduction
Pharmacological Therapy for
Management of Stage C HFrEF
Recommendations
Diuretics
Diuretics are recommended in patients with HFrEF with fluid
retention
ACE Inhibitors
ACE inhibitors are recommended for all patients with HFrEF
ARBs
ARBs are recommended in patients with HFrEF who are ACE
inhibitor intolerant
ARBs are reasonable as alternatives to ACE inhibitor as first
line therapy in HFrEF
The addition of an ARB may be considered in persistently
symptomatic patients with HFrEF on GDMT
Routine combined use of an ACE inhibitor, ARB, and
aldosterone antagonist is potentially harmful
COR
LOE
I
C
I
A
I
A
IIa
A
IIb
A
III: Harm
C
Pharmacological Therapy for
Management of Stage C HFrEF (cont.)
Recommendations
Beta Blockers
Use of 1 of the 3 beta blockers proven to reduce mortality is
recommended for all stable patients
Aldosterone Antagonists
Aldosterone receptor antagonists are recommended in
patients with NYHA class II-IV HF who have LVEF ≤35%
Aldosterone receptor antagonists are recommended in
patients following an acute MI who have LVEF ≤40% with
symptoms of HF or DM
Inappropriate use of aldosterone receptor antagonists may be
harmful
Hydralazine and Isosorbide Dinitrate
The combination of hydralazine and isosorbide dinitrate is
recommended for African-Americans, with NYHA class III–
IV HFrEF on GDMT
A combination of hydralazine and isosorbide dinitrate can be
useful in patients with HFrEF who cannot be given ACE
inhibitors or ARBs
COR
LOE
I
A
I
A
I
B
III:
Harm
B
I
A
IIa
B
Pharmacologic Therapy for
Management of Stage C HFrEF (cont.)
Recommendations
Digoxin
Digoxin can be beneficial in patients with HFrEF
Anticoagulation
Patients with chronic HF with permanent/persistent/paroxysmal AF and an
additional risk factor for cardioembolic stroke should receive chronic
anticoagulant therapy*
The selection of an anticoagulant agent should be individualized
Chronic anticoagulation is reasonable for patients with chronic HF who have
permanent/persistent/paroxysmal AF but without an additional risk factor for
cardioembolic stroke*
Anticoagulation is not recommended in patients with chronic HFrEF without
AF, prior thromboembolic event, or a cardioembolic source
Statins
Statins are not beneficial as adjunctive therapy when prescribed solely for HF
Omega-3 Fatty Acids
Omega-3 PUFA supplementation is reasonable to use as adjunctive therapy in
HFrEF or HFpEF patients
COR
LOE
IIa
B
I
A
I
C
IIa
B
III: No
Benefit
B
III: No
Benefit
A
IIa
B
Pharmacological Therapy for
Management of Stage C HFrEF (cont.)
Recommendations
Other Drugs
Nutritional supplements as treatment for HF are not recommended
in HFrEF
Hormonal therapies other than to replete deficiencies are not
recommended in HFrEF
Drugs known to adversely affect the clinical status of patients with
HFrEF are potentially harmful and should be avoided or
withdrawn
Long-term use of an infusion of a positive inotropic drug is not
recommended and may be harmful except as palliation
Calcium Channel Blockers
Calcium channel blocking drugs are not recommended as routine
in HFrEF
COR
III: No
Benefit
III: No
Benefit
LOE
B
C
III: Harm
B
III: Harm
C
III: No
Benefit
A
HFSA 2010 Practice Guideline (7.11)
Pharmacologic Therapy: Beta Blockers
SYMPTOMATIC EXACERBATION
Continuation of beta blocker therapy is recommended in
most patients experiencing a symptomatic exacerbation of
HF during chronic maintenance treatment, unless they
develop cardiogenic shock, refractory volume overload, or
symptomatic bradycardia.
Strength of Evidence = C
 Temporary dose reduction may be considered
 Avoid abrupt discontinuation
 Reinstate or gradually increase prior to discharge
 Titrate dose to previously tolerated dose as soon as
possible
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
ACE Inhibitors in Heart Failure:
From Asymptomatic LVD to Severe HF
SOLVD Prevention
(Asymptomatic LVD)
CONSENSUS
(Severe Heart Failure)
20%
death or HF hosp.
40%
mortality at 6 mos.
29%
death or new HF
31%
mortality at 1 year
27%
mortality at end of
study
SOLVD Treatment
(Chronic Heart Failure)
16%
mortality

No difference in incidence
of sudden cardiac death
SOLVD Investigators. N Engl J Med 1992;327:685-91
SOLVD Investigators. N Engl J Med 1991;325:293-302
CONSENSUS Study Trial Group. N Engl J Med 1987;316:1429-35
Effect of Beta Blockade on Outcome
in Patients With HF and Post-MI LVD
HF
Severity
Target
Dose (mg)
Outcome
Study
Drug
US Carvedilol1
carvedilol
mild/
moderate
6.2525 BID
↓48% disease progression
(p= .007)
CIBIS-II2
bisoprolol
moderate/
severe
10 QD
↓34% mortality (p <.0001)
MERIT-HF3
metoprolol
succinate
mild/
moderate
200 QD
↓34% mortality (p = .0062)
COPERNICUS4
carvedilol
severe
25 BID
↓35% mortality (p = .0014)
CAPRICORN5
carvedilol
post-MI
LVD
25 BID
↓23% mortality (p =.031)
1Colucci
WS et al. Circulation 1196;94:2800-6. 2CIBIS II Investigators. Lancet 1999;353:9-13.
3MERIT-HF Study Group. Lancet 1999;353:2001-7. 4Packer M et al. N Engl J Med 2001;344
1651-8. 5The CAPRICORN Investigators. Lancet 2001;357:1385-90.
COPERNICUS: Death, Hospitalization, or
Study Drug Withdrawal in High Risk Patients
% of Patients With Event
30
HR = 0.67 (CI = 0.47-0.96)
20
Placebo
10
Carvedilol
0
0
2
4
6
Weeks After Randomization
8
Krum H et al. JAMA 2003;289:754-6
Krum et al. JAMA 2003;289
HFSA 2010 Practice Guideline
Pharmacologic Therapy: Beta Blocker Overview*
General
considerations
Initiate at low doses
Up-titrate gradually, generally no sooner than at 2 week
intervals
Use target doses shown to be effective in clinical trials
Aim to achieve target dose in 8-12 weeks
Maintain at maximum tolerated dose
If symptoms worsen
or other side effects
appear
Adjust dose of diuretic or concomitant vasoactive med.
If up-titration
continues to be
difficult
Prolong titration interval
Continue titration to target after symptoms return to
baseline
Reduce target dose
Consider referral to a HF specialist
*Consult language of specific recommendations
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.3)
Pharmacologic Therapy:
Angiotensin Receptor Blockers
ARBs are recommended for routine
administration to symptomatic and
asymptomatic patients with an
LVEF ≤ 40% who are intolerant to
ACE inhibitors for reasons other than
hyperkalemia or renal insufficiency.
Strength of Evidence = A
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
ARBS in Patients Not Taking ACE Inhibitors:
Val-HeFT & CHARM-Alternative
Val-HeFT
CHARM-Alternative
50
CV Death or HF Hosp %
Survival %
100
Valsartan
90
80
Placebo
70
Placebo
40
30
Candesartan
20
10
60
p = 0.017
HR 0.77, p = 0.0004
50
0
0
3
6
9
12
15
18
21
24
27
0
9
Months
18
27
Months
Maggioni AP et al. JACC 2002;40:1422-4
Granger CB et al. Lancet 2003;362:772-6
36
Angiotensin Receptor Blockers
Used in Clinical Trials
Generic
Name
Trade Name
Initial
Daily Dose
Target Dose
Mean Dose in
Clinical Trials
Candesartan
Atacand
4-8 mg qd
32 mg qd
24 mg/day
Losartan
Cozaar
12.5-25 mg qd
150 mg qd
129 mg/day
Valsartan
Diovan
40 mg bid
160 mg bid
254 mg/day
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.14-7.15)
Pharmacologic Therapy:
Aldosterone Antagonists
An aldosterone antagonist is recommended for
patients on standard therapy, including diuretics,
who have:

NYHA class IV HF (or class III, previously class IV) HF from
reduced LVEF (≤ 35%)
One should be considered in patients post-MI
with clinical HF or diabetes and an LVEF < 40%
who are on standard therapy, including an ACE
inhibitor (or ARB) and a beta blocker.
Strength of Evidence = A
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Aldosterone Antagonists in HF
EPHESUS (Post-MI)
Probability of Survival
RALES (Advanced HF)
1.00
1.00
0.90
0.90
0.80
Spironolactone
0.70
Eplerenone
0.80
Placebo
0.70
0.60
0.60
Placebo
0.50
0.50
RR = 0.70
P < 0.001
0.40
RR = 0.85
P < 0.008
0.40
0
3
6
9
12 15 18 21 24 27 30 33 36
0
3
6
9
12 15 18 21 24 27 30 33 36
Months
Pitt B. N Engl J Med 1999;341:709-17
Pitt B. N Engl J Med 2003;348:1309-21
HFSA 2010 Practice Guideline (7.16-7.18)
Aldosterone Antagonists and Renal Function
Aldosterone antagonists are not recommended when:
 Creatinine > 2.5mg/dL (or clearance < 30 mL/min)
 Serum potassium> 5.0 mmol/L
 Therapy includes other potassium-sparing diuretics
Strength of Evidence = A
It is recommended that potassium be measured at
baseline, then 1 week, 1 month, and every 3 months
Strength of Evidence = A
Supplemental potassium is not recommended unless
potassium is < 4.0 mmol/L
Strength of Evidence = A
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
after RALES: RX
Juurlink et al. NEJM 2004;351:543
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
after RALES::Death
Juurlink et al. NEJM 2004;351:543
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.19)
Pharmacologic Therapy:
Hydralazine and Oral Nitrates
A combination of hydralazine and
isosorbide dinitrate is recommended as
part of standard therapy, in addition to
beta-blockers and ACE-inhibitors, for
African Americans with HF and reduced
LVEF:
 NYHA III or IV HF
Strength of Evidence = A
 NYHA II HF
Strength of Evidence = B
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
A-HeFT All-Cause Mortality
43% Decrease in Mortality
100
Survival %
Fixed Dose ISDN/HDZN
95
90
Placebo
P = 0.01
85
0
100
200
Days Since Baseline Visit
300
400
500
600
Taylor AL et al. N Engl J Med 2004;351:2049-57
Treatment of Stages A to D
Treatment for Stage C HFpEF
Treatment of HFpEF
Recommendations
Systolic and diastolic blood pressure should be
controlled according to published clinical practice
guidelines
Diuretics should be used for relief of symptoms due to
volume overload
Coronary revascularization for patients with CAD in
whom angina or demonstrable myocardial ischemia is
present despite GDMT
Management of AF according to published clinical
practice guidelines for HFpEF to improve symptomatic
HF
Use of beta-blocking agents, ACE inhibitors, and ARBs
for hypertension in HFpEF
ARBs might be considered to decrease hospitalizations in
HFpEF
Nutritional supplementation is not recommended in
HFpEF
COR
LOE
I
B
I
C
IIa
C
IIa
C
IIa
C
IIb
B
III: No
Benefit
C
Figure 11.3. Diagnostic Algorithm
for HF with Preserved LVEF
HF with
Preserved LVEF
Dilated LV
Valvular disease
AR, MR
Non-dilated LV
No valvular dis.
High output HF
Increased
thickness
Normal or
increased QRS
Hypertrophic dis.
No aortic
valve disease
No hypertensive
history of PE
HCM, Fabry dis.
Low QRS voltage
Infiltrative
myopathy
Aortic valve dis.
Aortic stenosis
Hypertensive
history of PE
Hypertensive-HCM
Some patients with RV
dysfunction have LV
dysfunction due to
ventricular interaction.
Normal
Thickness
Right vent.
dysfunction
No mitral
obstruction
Pericardial dis.
Tamponade
Constriction
Pulmonary
hypertension
Isolated predominant RVMI
No pericardial
disease
Inducible ischemia
Intermittent/active
ischemia
Mitral obstruction
MS, atrial myxoma
No inducible ischemia, fibrotic, collagenVascular, RCM, cardinoid, diabetes,
Radiation or chemotherapy induced
heart disease, infiltrative disease, comorbid conditions, reconsider diagnosis
of HF
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (11.8, 15.2)
Pharmacologic Therapy: Beta Blockers
PRESERVED LVEF
Beta blocker treatment is recommended in patients with HF and
preserved LVEF who have:

Prior MI
Strength of Evidence = A

Hypertension
Strength of Evidence = B

Atrial fib. requiring control of ventricular rate
Strength of Evidence = B
Strength of Evidence = C
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
The Hospitalized Patient
Diuretics in Hospitalized
Patients
HFSA 2010 Practice Guideline (7.23)
Pharmacologic Therapy: Diuretics
Diuretic therapy is recommended to restore and
maintain normal volume status in patients with
clinical evidence of fluid overload, generally
manifested by:
 Congestive symptoms
 Signs of elevated filling pressures
Strength of Evidence = A
Loop diuretics rather than thiazide-type diuretics
are typically necessary to restore normal volume
status in patients with HF.
Strength of Evidence = B
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
HFSA 2010 Practice Guideline (7.24)
Pharmacologic Therapy: Diuretics
 Restoration of normal volume status may require multiple
adjustments.
 Once a diuretic effect is achieved with short-acting loop
diuretics, increase frequency to 2-3 times a day if necessary,
rather than increasing a single dose. Strength of Evidence = B
 Oral torsemide may be considered in patients exhibiting poor
absorption of oral medication or erratic diuretic effect.
Strength of Evidence = C
 IV administration of diuretics may be necessary.
Strength of Evidence = A
 Diuretic refractoriness may represent patient nonadherence,
a direct effect of diuretic use on the kidney, or progression of
underlying dysfunction.
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Loop Diuretics
Agent
Initial Daily
Dose
Max Total
Daily Dose
Elimination: Duration of
Renal – Met. Action
Furosemide
20-40mg qd
or bid
600 mg
65%R-35%M 4-6 hrs
Bumetanide
0.5-1.0 mg
qd or bid
10 mg
62%R/38%M 6-8 hrs
Torsemide
10-20 mg qd
200 mg
20%R-80%M 12-16 hrs
Ethacrynic
acid
25-50 mg qd
or bid
200 mg
67%R-33%M 6 hrs
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Potassium-Sparing Diuretics
Agent
Initial Daily
Dose
Max Total
Daily Dose
Elimination
Duration
of Action
Spironolactone
12.5-25 mg
qd
50 mg
Metabolic
48-72 hrs
Eplerenone
25-50 mg
qd
100 mg
Renal,
Metabolic
Unknown
Amiloride
5 mg qd
20 mg
Renal
24 hrs
Triamterene
50-75 mg
bid
200 mg
Metabolic
7-9 hrs
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Therapies in the Hospitalized HF Patient
Recommendation
COR
LOE
HF patients hospitalized with fluid overload should be treated with
intravenous diuretics
I
B
HF patients receiving loop diuretic therapy, should receive an initial
parenteral dose greater than or equal to their chronic oral daily dose, then
should be serially adjusted
I
B
HFrEF patients requiring HF hospitalization on GDMT should continue
GDMT unless hemodynamic instability or contraindications
I
B
Initiation of beta-blocker therapy at a low dose is recommended after
optimization of volume status and discontinuation of intravenous agents
I
B
Thrombosis/thromboembolism prophylaxis is recommended for patients
hospitalized with HF
I
B
Serum electrolytes, urea nitrogen, and creatinine should be measured
during the titration of HF medications, including diuretics
I
C
Therapies in the Hospitalized HF Patient
(cont.)
Recommendation
COR
LOE
B
When diuresis is inadequate, it is reasonable to
a) Give higher doses of intravenous loop diuretics; or
b) add a second diuretic (e.g., thiazide)
IIa
Low-dose dopamine infusion may be considered with loop diuretics to
improve diuresis
IIb
B
Ultrafiltration may be considered for patients with obvious volume
overload
IIb
B
Ultrafiltration may be considered for patients with refractory congestion
IIb
C
Intravenous nitroglycerin, nitroprusside or nesiritide may be considered an
adjuvant to diuretic therapy for stable patients with HF
IIb
B
In patients hospitalized with volume overload and severe hyponatremia,
vasopressin antagonists may be considered
IIb
B
B
HFSA 2010 Practice Guideline (12.25, Table 12.7)
Discharge Criteria for Hospitalized ADHF Patients
Recommended prior to discharge for all patients with HF:

Exacerbating factors addressed

Near optimum fluid status and pharmacologic therapy achieved

Transition from IV to oral diuretic completed

Patient education completed with clear discharge instructions

Follow-up clinic visit scheduled, usually 7-10 days
Should be considered prior to discharge for patients with
advanced HF or a history of recurrent admissions:

Oral regimen stable for 24 hours

No IV inotrope or vasodilator for 24 hours

Ambulation before discharge to assess functional capacity

Plans for post-discharge management

Referral for disease management, if available
Strength of Evidence =C
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
Hospital Discharge
Recommendation or Indication
COR
LOE
Performance improvement systems in the hospital and early postdischarge outpatient setting
to identify HF for GDMT
I
B
Before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits,
the following should be addressed:
a) initiation of GDMT if not done or contraindicated;
b) causes of HF, barriers to care, and limitations in support;
c) assessment of volume status and blood pressure with adjustment of HF therapy;
d) optimization of chronic oral HF therapy;
e) renal function and electrolytes;
f) management of comorbid conditions;
g) HF education, self-care, emergency plans, and adherence; and
h) palliative or hospice care.
I
B
I
B
IIa
B
IIa
B
Multidisciplinary HF disease-management programs for patients at high risk for hospital
readmission are recommended
A follow-up visit within 7 to 14 days and/or a telephone follow-up within 3 days of hospital
discharge is reasonable
Use of clinical risk-prediction tools and/or biomarkers to identify higher-risk patients is
reasonable
HFSA 2010 Practice Guideline (8.1)
Heart Failure Patient Education
 It is recommended that patients with HF and
their family members or caregivers receive
individualized education and counseling that
emphasizes self-care.
 This education and counseling should be
delivered by providers using a team approach.
 Referral to HF Disease Management Program
Metrics to consider include the 6-minute walk
test and NYHA functional class
Strength of Evidence = B
Adapted from:
Lindenfeld J, et al. HFSA 2010 Comprehensive
Heart Failure Guideline. J Card Fail 2010;16:e1-e194.
The Potential Impact of Effective
Education on Patient Compliance
Nonadherence rate when patients . . .
Recall MD advice
Don’t recall advice
Medications
8.7%
66.7%
Diet
23.6%
55.8%
Activity
76.4%
84.5%
Smoking
60.0%
90.4%
Alcohol
60.0%
81.8%
Kravitz et al. Arch Int Med 1993;153:1869-78
HF Disease Management and the
Risk of Readmission
1.1
Risk
Ratio
Ekman
1
0.9
0.8
Jaarsma
0.7 Cline
Lasater
Stewart
Rich
Rauh
Venner
0.6
Naylor
Fonarow
0.5
Summary RR = 0.76 (95% CI .68-.87)
Summary RR for randomized only = 0.75 (CI = .60-.95)
Guideline for HF
Quality Metrics/Performance
Measures
ACCF/AHA/AMA-PCPI 2011 HF Performance
Measurement Set
Measure
1. LVEF
assessment
2. LVEF
assessment
3. Symptom
and activity
assessment
Description*
Care
Level of
Setting
Measurement
Percentage of patients aged ≥18 y with a diagnosis of HF for whom the Outpatient Individual
quantitative or qualitative results of a recent or prior (any time in the
practitioner
past) LVEF assessment is documented within a 12 mo period
Percentage of patients aged ≥18 y with a principal discharge diagnosis Inpatient
·
Individual
of HF with documentation in the hospital record of the results of an
practitioner
LVEF assessment that was performed either before arrival or during
·
Facility
hospitalization, OR documentation in the hospital record that LVEF
assessment is planned for after discharge
Percentage of patient visits for those patients aged ≥18 y with a
Outpatien Individual
diagnosis of HF with quantitative results of an evaluation of both
t
practitioner
current level of activity and clinical symptoms documented
*Please refer to the complete measures for comprehensive information, including measure exception.
Adapted from Bonow et al. J Am Coll Cardiol. 2012;59:1812-32.
ACCF/AHA/AMA-PCPI 2011 HF Performance Measurement Set
(cont.)
Measure
4. Symptom
management†
5. Patient selfcare education†‡
6. Beta-blocker
therapy for LVSD
(outpatient and
inpatient setting)
Description*
Percentage of patient visits for those patients aged ≥18 y with a
diagnosis of HF and with quantitative results of an evaluation of both
level of activity AND clinical symptoms documented in which patient
symptoms have improved or remained consistent with treatment goals
since last assessment OR patient symptoms have demonstrated
clinically important deterioration since last assessment with a
documented plan of care
Percentage of patients aged ≥18 y with a diagnosis of HF who were
provided with self-care education on ≥3 elements of education during
≥1 visits within a 12 mo period
Percentage of patients aged ≥18 y with a diagnosis of HF with a
current or prior LVEF <40% who were prescribed beta-blocker
therapy with bisoprolol, carvedilol, or sustained release metoprolol
succinate either within a 12 mo period when seen in the outpatient
setting or at hospital discharge
Care
Setting
Outpatient
Level of
Measurement
Individual
practitioner
Outpatient
Individual
practitioner
Inpatient
Individual
and
practitioner
Outpatient Facility
*Please refer to the complete measures for comprehensive information, including measure exception.
†Test measure designated for use in internal quality improvement programs only. These measures are not appropriate for any other
purpose, e.g., pay for performance, physician ranking or public reporting programs.
‡New measure.
Adapted from Bonow et al. J Am Coll Cardiol. 2012;59:1812-32.
ACCF/AHA/AMA-PCPI 2011 HF Performance Measurement Set
(cont.)
Measure
Description*
Care Setting
Level of
Measurement
Individual
practitioner
Facility
7. ACE Inhibitor or
ARB Therapy for
LVSD (outpatient and
inpatient setting)
8. Counseling
regarding ICD
implantation for
patients with LVSD on
combination medical
therapy†‡
9. Post-discharge
appointment for heart
failure patients
Percentage of patients aged ≥18 y with a diagnosis of HF with a
current or prior LVEF <40% who were prescribed ACE inhibitor or
ARB therapy either within a 12 mo period when seen in the outpatient
setting or at hospital discharge
Percentage of patients aged ≥18 y with a diagnosis of HF with current
LVEF ≤35% despite ACE inhibitor/ARB and beta-blocker therapy for
at least 3 mo who were counseled regarding ICD implantation as a
treatment option for the prophylaxis of sudden death
Inpatient
and
Outpatient
Outpatient
Individual
practitioner
Percentage of patients, regardless of age, discharged from an inpatient
facility to ambulatory care or home health care with a principal
discharge diagnosis of HF for whom a follow-up appointment was
scheduled and documented including location, date and time for a
follow-up office visit, or home health visit (as specified)
Inpatient
Facility
*Please refer to the complete measures for comprehensive information, including measure exception.
†Test measure designated for use in internal quality improvement programs only. These measures are not appropriate for any other
purpose, e.g., pay for performance, physician ranking or public reporting programs.
‡New measure.
Adapted from Bonow et al. J Am Coll Cardiol. 2012;59:1812-32.
Thank You
www.acc.org/clinical/guidelines/failure//index.pdf