Heart Failure Society of America Joins ACC and AHA to Update Heart Failure Guidelines

Updated guidelines for the treatment of heart failure (HF) were recently published in Circulation.¹ The previous version, authored by the American College of Cardiology (ACC) and the American Heart Association (AHA), was published in 2013.² The Heart Failure Society of America (HFSA) collaborated with the ACC and AHA for this new publication. Moving forward, HFSA will continue to offer joint guidance on HF management. 

Based on data available since the 2013 guidelines were published, the new document includes revisions or additions to the following sections.

Biomarkers

There has been an increase in the use of testing for natriuretic peptide biomarkers, specifically B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP), to determine HF diagnosis and prognosis. Evidence supports the benefits of such screenings and early intervention in preventing new-onset HF.³

Research also supports a role for these assays, as well as cardiac troponins and other biomarkers, in establishing HF prognosis and risk stratification. “Biomarkers of myocardial fibrosis, soluble ST2 receptor, and galectin-3 are predictive of hospitalization and death and may provide incremental prognostic value over natriuretic peptide levels in patients with HF,” the authors wrote.⁴

New Treatments for Stage C HF With Reduced Ejection Fraction

To decrease morbidity and mortality in patients with HF with reduced ejection fraction (HFrEF), the use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, (ARBs) or angiotensin receptor neprilysin inhibitors (ARNI) combined with evidence-based beta-blockers (plus aldosterone antagonists in certain patients) is recommended.^5,6 The guidelines cover potential adverse effects and contraindications for each class of drugs, as well as the optimal class for various types of patients.

In light of new findings, the authors warned against the concomitant use of ARNIs and ACE inhibitors, as the combination may lead to angioedema. ARNIs should not be used until 36 hours have passed since the last administration of an ACE inhibitor.⁷ In addition, ARNIs may lead to a recurrence of angioedema in patients with such a history, and should be avoided in these individuals.

Data on the use of ivabradine to reduce HF hospitalization in selected patients with HFrEF were also reviewed.

Updates on HF With Preserved Ejection Fraction

New evidence-based recommendations include the use of aldosterone receptor agonists to reduce hospitalizations in certain patients with HF with preserved ejection fraction (HFpEF) with EF ≥45% and specified biomarkers. Additionally, recent findings have shown that that routine “use of nitrates or phosphodiesterase-5 inhibitors to increase activity or [quality of life] in patients with HFpEF is ineffective,” as reported in the paper.^8,9

Key Comorbidities in HF

The guidelines have been updated to reflect emerging evidence regarding treatment of comorbidities such as anemia and sleep-disordered breathing, as well as a new section on hypertension, including its management in patients with HF of various stages and types.

“Guideline recommended management is effective only when followed by healthcare providers and patients,” the authors wrote. “Adherence to recommendations can be enhanced by shared decision making between healthcare providers and patients, with patient engagement in selecting interventions based on individual values, preferences, and associated conditions and comorbidities.”

References

1. 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: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America [published online April 28, 2017]. Circulation. doi:10.1161/CIR.0000000000000509
2. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147-239. doi:10.1016/j.jacc.2013.05.019
3. Ledwidge M, Gallagher J, Conlon C, et al. Natriuretic peptide-based screening and collaborative care for heart failure: the STOP-HF randomized trial. JAMA. 2013;310(1):66-74. doi:10.1001/jama.2013.7588
4. Ahmad T, Fiuzat M, Neely B, et al. Biomarkers of myocardial stress and fibrosis as predictors of mode of death in patients with chronic heart failure. JACC Heart Fail. 2014;2(3):260-268. doi:10.1016/j.jchf.2013.12.004
5. Eschalier R, McMurray JJV, Swedberg K, et al. Safety and efficacy of eplerenone in patients at high risk for hyperkalemia and/or worsening renal function: analyses of the EMPHASIS-HF study subgroups (Eplerenone in Mild Patients Hospitalization And Survival Study in Heart Failure). J Am Coll Cardiol. 2013;62(17):1585-1593. doi:10.1016/j.jacc.2013.04.086
6. Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med. 1999;341(10):709-717. doi:10.1056/NEJM199909023411001
7. Packer M, Califf RM, Konstam MA, et al. Comparison of omapatrilat and enalapril in patients with chronic heart failure: the Omapatrilat Versus Enalapril Randomized Trial of Utility in Reducing Events (OVERTURE). Circulation. 2002;106(8):920-926.
8. Redfield MM, Anstrom KJ, Levine JA, et al. Isosorbide mononitrate in heart failure with preserved ejection fraction. N Engl J Med. 2015;373(24):2314-2324. doi:10.1056/NEJMoa1510774  
9. Redfield MM, Chen HH, Borlaug BA, et al. Effect of phosphodiesterase-5 inhibition on exercise capacity and clinical status in heart failure with preserved ejection fraction: a randomized clinical trial. JAMA. 2013;309(12):1268-1277. doi:10.1001/jama.2013.2024