Review

Heart failure guidelines: What you need to know about the 2017 focused update

Lee Rodney Haselhuhn MD, Daniel J. Brotman MD and Ilan Shor Wittstein MD
Cleveland Clinic Journal of Medicine February 2019, 86 (2) 123-139; DOI: https://doi.org/10.3949/ccjm.86a.18022

Article Figures & Data

Tables

  • TABLE 1

    Heart failure stages and functional classes

    NYHA class INYHA class IINYHA class IIINYHA class IV
    No physical limitationsSlight limitation of physical activityMarked limitation of physical activitySymptoms at rest
    Stage AStage BStage CStage D
    Patients at risk for heart failure
    No structural disease    		Structural disease
    No heart failure symptoms    		Structural disease
    Heart failure symptoms    		End-stage disease

    • NYHA = New York Heart Association

    • Reprinted from Okwuosa IS, Princewill O, Nwabueze C, et al. The ABCs of managing systolic heart failure: past, present, and future. Cleve Clin J Med 2016; 83(10):753-765. doi:10.3949/ccjm.83a.16006

  • TABLE 2

    Recommendations for measuring biomarkers in heart failure

    Patient groupClassa
    At risk of heart failure
    BNP or NT-proBNP for preventionIIa
    Ambulatory with new-onset dyspnea
    BNP or NT-proBNP for diagnosisI
    With NYHA class II-IV symptoms
    BNP or NT-proBNP for prognosisI
    Other biomarkers of myocardial injury or fibrosisb for prognosisIIb
    With acute dyspnea in the emergency department
    BNP or NT-proBNP for diagnosisI
    BNP or NT-proBNP, and cardiac troponin for prognosisI
    Hospitalized for acute decompensated heart failure
    BNP or NT-proBNP, and cardiac troponin for prognosisI
    BNP or NT-proBNP before discharge for prognosisIIa
    Other biomarkers of myocardial injury or fibrosisb for prognosisIIb

    • ↵a Class of recommendation (I strong, Ila moderate, Ilb weak).

    • ↵b For example, soluble ST2 receptor, galectin-3, and high-sensitivity troponin.

    • BNP = B-type natriuretic peptide; NT-proBNP = N-terminal pro-B-type natriuretic peptide; NYHA = New York Heart Association

    • Information from reference 1.

  • TABLE 3

    Recommendations for patients with heart failure with preserved ejection fraction

    RecommendationClassa
    Aldosterone receptor antagonistsbIIb
    Angiotensin II receptor blockersIIb
    Routine use of nitrates or phosphodiesterase-5 inhibitors is ineffectiveIII

    • ↵a Class of recommendation (I strong, Ila moderate, Ilb weak, III no benefit).

    • ↵b In patients with ejection fraction ≥ 45%, elevated B-type natriuretic peptide levels or heart failure admission within 1 year, estimated glomerular filtration rate > 30 mL/ min, creatinine < 2.5 mg/dL, potassium < 5.0 mmol/L.

    • Information from reference 1.

  • TABLE 4

    Recommendations for managing blood pressure in heart failure

    Patient groupClassa
    With hypertension at increased risk
    < 130/80 mm Hg should be the optimal blood pressureI
    With heart failure with reduced ejection fraction
    Guideline-directed medical treatment titrated to attain a blood pressure of < 130/80 mm HgI
    Nondihydropyridine calcium channel blockers not recommendedIII
    With heart failure with preserved ejection fraction and symptoms of volume overload
    Diuretics to control hypertensionI
    With heart failure with preserved ejection fraction and persistent hypertension after management of volume overload
    Guideline-directed medical therapy titrated to attain systolic blood pressure < 130 mm Hg. Although there are limited data to guide the choice of antihypertensive therapy in HFpEF, preferred agents include RAAS inhibition with ACE-I, ARB, and mineralocorticoid receptor antagonists (spironolactone).I
    Nitrates not recommended in HFpEF, unless given for symptomatic coronary artery disease, due to association with a signal of harm or decreased exercise tolerance.III

    • ↵a Class of recommendation (I strong, III no benefit).

    • ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; HFpEF = heart failure with preserved ejection fraction; RAAS = renin-angiotensin-aldosterone system

    • Information from reference 1.

  • TABLE 5

    Studies of sleep-disordered breathing in heart failure

    SERVE-HF54 (Treatment of Sleep-Disordered Breathing With Predominant Central Sleep Apnea by Adaptive Servo Ventilation in Patients With Heart Failure)
    Aim: To determine whether adaptive servo-ventilation, a form of noninvasive ventilation that automatically adjusts to give the right amount of inspiratory pressure support upon inhalation, vs standard therapy alone could decrease morbidity and mortality in heart failure with reduced ejection fraction and predominantly central sleep apnea as was suggested by a post hoc analysis of a previous trial.52
    Design: Multicenter, single-blind randomized controlled trial, N = 1,325
    Primary end point: Composite end point of time to event for death from any cause, lifesaving cardiovascular intervention (transplant, left ventricular assist device, defibrillation), or unplanned hospitalization for heart failure over 5 years.
    Findings: Not only was there no significant change in the primary end point, the treatment arm actually showed a significant increase in cardiovascular (hazard ratio 1.34, P= .0006) and all-cause (hazard ratio 1.28, P= .01) mortality. One prominent but hotly debated hypothesis is that the Cheyne-Stokes respirations in central sleep apnea are compensatory in severe heart failure, perhaps allowing the pulmonary musculature to rest, attenuating sympathetic nervous system activity, and avoiding acidosis due to hypercapnia.
    SAVE56 (Sleep Apnea Cardiovascular Endpoints)
    Aim: To determine whether continuous positive airway pressure (CPAP) plus standard therapy vs standard therapy alone would decrease cardiovascular events in patients with moderate to severe obstructive sleep apnea and known coronary or cerebrovascular disease.
    Design: Multicenter, randomized controlled trial, N = 2,717
    Primary end point: Composite end point of death from cardiovascular cause, myocardial infarction, stroke, or hospitalization for unstable angina, heart failure, or transient ischemic attack over nearly 4 years.
    Secondary end points: Cardiovascular secondary end points included the individual components of the primary composite end point, other composites of cardiovascular events, revascularization procedures, new-onset atrial fibrillation, new-onset diabetes mellitus, and death from any cause. Noncardiovascular end points included daytime sleepiness, snoring, mood (depression, anxiety), and quality-of-life scores.
    Findings: Contrary to prior observational studies and despite a marked improvement in apneic-hypopneic events with CPAP (29/hour to 3.7/hour), no significant difference in the primary composite end point (17% vs 15.4%, P= .34) or cardiovascular secondary end points was evident. Significant improvement was seen in the noncardiovascular secondary end points such as daytime sleepiness, snoring, mood (depression, anxiety), and quality-of-life scores.
  • TABLE 6

    Recommendations on sleep apnea in heart failure

    Patient groupClassa
    With New York Heart Association (NYHA) class II-IV heart failure and suspicion of sleep-disordered breathing or excessive daytime sleepiness
    A formal sleep assessment to distinguish obstructive vs central sleep apnea is reasonableIIa
    With cardiovascular disease and obstructive sleep apnea
    Continuous positive airway pressure may be reasonable to improve sleep apnea and reduce daytime sleepinessIIb
    With NYHA class II-IV heart failure with reduced ejection fraction and central sleep apnea
    Adaptive servo-ventilation causes harmIII

    • ↵a Class of recommendation (IIa moderate, IIb weak, III harm).

    • Information from reference 1.

  • TABLE 7

    Iron deficiency in heart failure: Upcoming trials

    FAIR-HF271 (Intravenous Iron in Patients With Systolic Heart Failure and Iron Deficiency to Improve Morbidity and Mortality)
    Estimated completion: October 2020
    AFFIRM-AHF72 (Study to Compare Ferric Carboxymaltose With Placebo in Patients With Acute Heart Failure and Iron Deficiency)
    Estimated completion: June 2019
    HEART-FID73 (Randomized Placebo-controlled Trial of FCM as Treatment for Heart Failure With Iron Deficiency)
    Estimated completion: January 2021
    IRONMAN74 (Effectiveness of intravenous iron treatment vs standard care in patients with heart failure and iron deficiency)
    Estimated completion: February 2021
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