In addition to recommending the treatment for patients with mild to moderate disease, the guideline targets it more specifically. "We gave the greatest strength of recommendation for patients with a wide QRS interval and left bundle branch block, a modest recommendation for patients with a less wide interval, and an equivocal recommendation for those without left bundle branch block. We think this will allow better discrimination of those who are most likely to benefit from CRT from those unlikely to benefit."
There are also more plentiful data in favor of mechanical circulatory support for patients with advanced heart failure. "This is no longer a proof of concept strategy," Dr. Yancy said. "Left ventricular assist devices for advanced chronic heart failure represent an important component of a contemporary treatment algorithm for heart failure."
The guideline even reaches past the mechanics of heart failure into its possible genetic origins. "We’ve discovered that idiopathic dilated cardiomyopathy may not really be idiopathic, but instead related to genetic abnormality. We’ve coalesced observations and data from this emerging field to come up with recommendations about when we might consider genetic testing in patients and screening in family members. It’s something new, and we’re delighted that it’s presented in this document."
The guidelines also offer a new outlook on reducing heart failure readmissions – a problem that comes with a $25 billion/year price tag, Dr. Yancy said. Four simple, low-tech interventions stood out as practical and effective:
• Using in-hospital systems that identify heart failure patients appropriate for GDMT and prompt physicians to advance this care and assess response.
• Developing transitional care and discharge planning that emphasizes patient education to increase treatment compliance, manage comorbid conditions effectively, and tackle psychosocial barriers to care.
• Harnessing the cooperative power of a nurse-led multidisciplinary heart failure disease management program.
• Following up every patient with a phone call within 3 days of discharge and a physician appointment within 2 weeks.
"The beauty of this is that while everyone is looking for the silver bullet to decrease readmission – including high-tech interventions like device implantation and home electronic monitoring – we believe that these simple, straightforward, evidence-based approaches will work."
Finally, Dr. Yancy said, document places great importance on patient-centric outcomes like quality-of-life issues, shared decision-making, care coordination, and palliative care. Over the past decade, the physician/patient relationship has changed from almost paternalistic to an active partnership. "We need to include the patient’s point of view in this whole process. We need to put a greater emphasis on quality of life, and we need not fear a discussion on quality of death."
Dr. Yancy expressed a firm belief that integrating the guidelines into daily practice could have an enormous impact on the way heart failure patients are treated.
"We have come so far in our understanding and ability to treat these patients. These are dramatically effective interventions. We can shift the culture to the belief that heart failure is something that we can treat – to the idea that you can help your patients feel better and live longer. If we use this correctly, we can make a difference."
Dr. Yancy had no financial declarations.