Cardiology groups issue guidance on heart failure

The American Heart Association (AHA), American College of Cardiology (ACC), and Heart Failure Society of America (HFSA) issued a focused update last week on management of heart failure.

The focused update is an update of the 2013 guidelines from the ACC Foundation and the AHA. It addresses biomarkers; new therapies for stage C heart failure with reduced ejection fraction; heart failure with preserved ejection fraction; new data on important comorbidities, including sleep apnea, anemia, and hypertension; and new insights into heart failure prevention. It was published online by Journal of the American College of Cardiology, Circulation, and the Journal of Cardiac Failure on April 28.

New recommendations include the following:

• During a hospitalization for heart failure, measurement of a predischarge natriuretic peptide level can be useful to establish prognosis postdischarge.
• To reduce morbidity and mortality in patients with chronic heart failure and reduced ejection fraction, inhibition of the renin-angiotensin system with angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), or angiotensin receptor-neprilysin inhibitors (ARNIs) in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended.
• In patients with chronic symptomatic New York Heart Association (NYHA) class II or III heart failure and reduced ejection fraction who tolerate an ACE inhibitor or ARB, replacement by an ARNI is recommended to further reduce morbidity and mortality.
• An ARNI should not be administered concomitantly with ACE inhibitors or within 36 hours of the last dose of an ACE inhibitor.
• ANRIs should not be given to patients with a history of angioedema.
• Ivabradine, a recently approved drug that lowers the heart rate through a mechanism different than beta-blockade, can be beneficial to reduce heart failure hospitalization for patients with symptomatic (NYHA class II to III) stable chronic heart failure and reduced ejection fraction who are receiving guideline-directed evaluation and management, including a beta-blocker at maximum tolerated dose, and who are in sinus rhythm with a heart rate of 70 beats/min or greater at rest.
• Routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or quality of life in patients with heart failure and preserved ejection fraction is ineffective.
• In patients with NYHA class II and III heart failure and iron deficiency (ferritin level <100 ng/mL or 100 to 300 ng/mL if transferrin saturation is <20%), IV iron replacement might be reasonable to improve functional status and quality of life.
• In patients with heart failure and anemia, erythropoietin-stimulating agents should not be used to improve morbidity and mortality.
• In patients with stage A heart failure at increased risk, optimal blood pressure in those with hypertension should be less than 130/80 mm Hg.
• Patients with heart failure and preserved ejection fraction in whom hypertension persists after management of volume overload should be prescribed guideline-directed medical therapy titrated to attain systolic blood pressure less than 130 mm Hg.
• In patients with NYHA class II to IV heart failure and suspicion of sleep disordered breathing or excessive daytime sleepiness, a formal sleep assessment is reasonable.
• In patients with NYHA class II to IV heart failure with reduced ejection fraction and central sleep apnea, adaptive servo-ventilation causes harm.

Also last week, the AHA released a separate scientific statement on the role of biomarkers for prevention, assessment, and management of heart failure. The statement reviewed evidence through December 2016 and addresses the pathophysiological role of biomarkers in heart failure, assessment of risk for incident heart failure, use of biomarkers for the diagnosis and prognosis of heart failure, outpatient management of heart failure, and management of hospitalization. The scientific statement is available online and was published April 26 by Circulation.