Updated guidelines on heart failure issued by the American College of Cardiology and the American Heart Association include new recommendations on managing hospitalized patients and strengthened guidance on the use of hydralazine and isosorbine dinitrate in African Americans.
Heart failure, the leading cause of hospitalization of patients over age 65 years, “is responsible for a huge portion of the costs associated with cardiovascular disease,” Dr. Mariell Jessup, chair of the group that wrote the guidelines, noted in a statement.
“These guidelines strive to reflect the most recent information coming out of the clinical trials on heart failure,” said Dr. Jessup, who is a professor of medicine and director of the heart failure and transplant program at the University of Pennsylvania in Philadelphia.
Developed as a consensus of expert opinion based on review of late-breaking clinical trials and other data, the 2009 focused update was published in the Journal of the American College of Cardiology (J. Am. Coll. Cardiol. 2009;53:1353–82) and in Circulation.
The new section on the management of hospitalized patients with acute heart failure was developed in response to the growing importance of the topic. “A number of recent HF trials reviewed for this update were, in fact, performed on hospitalized patients, and a number of newer therapies are under development for this population. Moreover, there is increasing government and other third-party payer interest in the prevention of HF hospitalizations and rehospitalization,” the writing committee noted.
The section on hospital care includes guidance on establishing etiology, assessments that should be performed, and guidance on transitioning of patients to home care, including a new medication regimen and a plan for detecting signs that warrant immediate medical attention.
The update strengthens recommendations on using the combination of hydralazine and isosorbide dinitrate in African American patients, citing clinical trial evidence that this patient population benefits from the addition of this combination to standard therapy with an ACE inhibitor and/or a beta blocker.
“This combination is recommended for African Americans who remain symptomatic despite optimal medical therapy,” according to the update, developed in collaboration with the International Society for Heart and Lung Transplantation.
The guidelines also provide streamlined information on using implantable cardioverter defibrillators and cardiac resynchronization devices, and clarify treatment goals in patients who have both heart failure and atrial fibrillation.
In addition, the update clarifies the use of testing for natriuretic peptides (B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide) for evaluating risk in patients in the urgent care setting, and upgrades the level of evidence against routine intermittent infusions of vasoactive drugs and positive inotropic drugs for patients with refractory end-stage heart failure.
The new guidelines represent a focused revision of comprehensive recommendations that were issued in 2005. The focused update process allows updates to be published on an as-needed basis, based on review of evidence at least twice a year. Recommendations on heart failure management that are not addressed in the update remain current.
Dr. Jessup reported that she was a consultant for Acorn, CardioMEMS, GlaxoSmithKline, Medtronic, Scios, and Ventracor. The other members of the guideline group also reported potential conflicts of interest with various pharmaceutical and medical device companies.
'These guidelines strive to reflect the most recent information coming out of the clinical trials on heart failure.' DR. JESSUP