Section III: Neurohormonal strategies in heart failure F. Optimal management of heart failure—Assessing new guidelines ACC/AHA guidelines for HF therapy in 4 stages Content Points: The American College of Cardiology (ACC) and the American Heart Association (AHA) have issued new guidelines for evaluation and management of HF, developed in collaboration with the International Society for Heart and Lung Transplantation and endorsed by the HF Society of America.57 The new classification recognizes that HF is a progressive disease with established risk factors, that the evolution of HF has asymptomatic and symptomatic phases, and that therapeutic interventions at each stage (even prior to the appearance of LV dysfunction or symptoms) can reduce the morbidity and mortality of HF. The new classification is intended to complement but not replace the NYHA functional classification, which is primarily a subjective gauge of the severity of symptomatic disease (stages C and D), and in which treatments do not differ significantly across HF classes. Stages A and B do not qualify for the traditional clinical diagnosis of HF, but they represent the emphasis on early intervention and prevention that the new guidelines emphasize. The new approach to HF identifies four stages in the evolution of HF, which are linked to treatments uniquely appropriate for each stage. – Stage A: patients at high risk for developing HF, but with no structural disorder of the heart – Stage B: patients with structural disorder of the heart who have never developed symptoms of HF – Stage C: patients with past or current HF symptoms associated with underlying structural heart disease – Stage D: patients with end-stage disease who have marked HF symptoms at rest despite maximal medical therapy Patients would be expected to advance from one stage to the next unless progression of the disease is slowed or stopped by treatment. Ongoing evaluation of the patient’s clinical status is critical to appropriate selection and monitoring of treatment.

ACC/AHA guidelines for HF therapy: Stages A and B Content Points: Stage A includes patients at high risk of developing LV dysfunction. Many conditions or behaviors associated with increased risk of HF can be identified before patients show evidence of structural heart disease. Early modification of these risk factors can often reduce the risk of HF.57 Treatment recommendations for stage A patients include: – Treatment of lipid disorders and high BP in accordance with current guidelines – Lifestyle changes, including encouragement of regular exercise, smoking cessation, reduction of alcohol intake, and cessation of illicit drug use – ACE inhibition for patients with a history of atherosclerotic vascular disease, diabetes, or hypertension and associated cardiovascular risk factors. Stage B includes patients with LV dysfunction who have not developed symptoms. Patients without symptoms who have had a MI or those with LV dysfunction are at considerable risk of developing HF. The likelihood can be diminished by therapies that reduce the risk of further injury, the process of remodeling, and progression of LV dysfunction. Treatment recommendations for stage B patients include: – ACE inhibition for patients with a current or past MI, regardless of ejection fraction, and for patients with a reduced ejection fraction even without a history of MI – ß-Blockade for patients with a recent MI, regardless of ejection fraction, and for patients with a reduced ejection fraction, whether or not they have experienced MI – All Stage A measures.

ACC/AHA guidelines for HF therapy: Stages C and D Content Points: Stage C includes patients with LV dysfunction with current or prior symptoms. All measures for stages A and B are appropriate for these patients. Treatment recommendations for Stage C patients include:57 –Drugs for routine use include a combination of four types: diuretic, ACE inhibitor, ß-blocker, and (usually) digitalis. Even if the patient has responded favorably to diuretic therapy, ACE inhibition and ß-blockade should be initiated and maintained (unless contraindicated) because of favorable effects on long-term prognosis. – Moderate sodium restriction is indicated along with daily weighing to permit effective use of lower and safer doses of diuretics. Physical activity should be encouraged. – All measures listed for patients in stages A and B. Stage D includes patients with refractory end-stage HF. Treatment recommendations for Stage D patients include: – All stage A, B, and C measures – Controlled trials suggest that patients with advanced HF respond well to treatment with both ACE inhibitors and ß-blockers in a manner similar to those with moderate disease. However, these patients may tolerate only small doses of neurohormonal antagonists, or may not tolerate them at all. – Meticulous control of fluid retention is essential, as many symptoms are related to fluid retention and patients respond well to interventions to restore balance. – These individuals should be considered for specialized treatment strategies.

ß-Blockade in HF Content Points: Care of HF has evolved dramatically over the past decade with the availability of treatment that changes the underlying biology of the failing heart. ß-Blockers have emerged as an important intervention for a broad range of patients as part of treatment that aims both to forestall development of HF and prevent the inexorable progression of the disease.57 Current guidelines for the management of HF recommend the use of ß-blockers in the majority of patients, ranging from patients at high risk of developing HF to patients with asymptomatic and symptomatic disease.