2009 ACCF/AHA Heart Failure Guidelines

2009 ACCF/AHA Heart Failure Guidelines from Sun YaiCheng

2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults

J. Am. Coll. Cardiol. April 14, 2009; 53;1343-1382

Circulation. April 14, 2009;119;1977-2016

Initial Clinical Assessment

• Coronary arteriography should be performed in HF who have angina or significant ischemia unless the pt is not eligible for revascularization.

• BNP or NT-proNBP can be useful in the urgent care setting in whom the clinical diagnosis of HF is uncertain. 
• Measurement of BNP can be helpful in risk stratification.

Patients with Reduced Left Ventricular Ejection Fraction

• Diuretics and salt restriction

• ACE inhibitors or angiotensin II receptor blockers

• beta blockers 

• Implantable Cardioverter-Defibrillatoras (ICD)

• ICD is recommended in pts with of HF and reduced LVEF who have a history of cardiac arrest, VF, or hemodynamically destabilizing VT.
• ICD is recommended for primary prevention of SCD to reduce total mortality in pts with non-ischemic DCM or IHD > 40 days post-MI, LVEF ≤ 35%, NYHA Fc II or III while receiving chronic optimal medical therapy, and who have expectation of survival with good functional status > 1 year.

• Resynchronization Therapy

• Digitalis

• Hydralazine and Nitrate Combination

• Positive Inotropic Drugs 

Recommendations for the Hospitalized Patient (New Recommendations)

Diagnosis of HF

Clinicians should determine the following:

• adequacy of systemic perfusion
• volume status
• contribution of precipitating factors and/or co-morbidities
• if the heart failure is new onset or an exacerbation of chronic disease
• whether it is associated with preserved normal or reduced ejection fraction

CXR, ECG, and echocardiography are key tests in this assessment

Patients Being Evaluated for Dyspnea

• BNP or NT-proBNP should be measured in pts being evaluated for dyspnea in which the contribution of HF is not known.

• Precipitating Factors for Acute HF

• ACS/coronary ischemia
• severe hypertension
• atrial and ventricular arrhythmias
• infections
• pulmonary emboli
• renal failure
• medical or dietary non-compliance

• Oxygen Therapy and Rapid Intervention 

• Intravenous Loop Diuretics

• Monitoring Fluid Intake and Output

• Intensifying the Diuretic Regimen

• Preserving End-Organ Performance

In pts with clinical evidence of hypotension associated with hypoperfusion and obvious evidence of elevated cardiac filling pressures (e.g., elevated jugular venous pressure; elevated PAWP), IV inotropic or vasopressor drugs should be administered to maintain systemic perfusion and preserve end-organ performance while more definitive therapy is considered.

• ACE inhibitors or ARBs and beta-blocker therapy

• Urgent Cardiac Catheterization and Revascularization

When pts present with acute HF and known or suspected acute myocardial ischemia due to occlusive coronary disease, especially when there are signs and symptoms of inadequate systemic perfusion.

• Severe Symptomatic Fluid Overload

in the absence of systemic hypotension, vasodilators such as IV NTG, nitroprusside or neseritide can be beneficial.

• Invasive Hemodynamic Monitoring

for carefully selected pts with acute HF who have persistent symptoms despite empiric adjustment of standard therapies, and

• whose fluid status, perfusion, or systemic or pulmonary vascular resistances are uncertain
• whose SBP remains low, associated with symptoms, despite initial therapy
• whose renal function is worsening with therapy
• who require parenteral vasoactive agents
• who may need consideration for advanced device therapy or transplantation

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