1. ACC Heart Failure Guidelines Slide Deck
Based on the ACC/AHA 2005 Guideline Update
for the Diagnosis and Management of
Chronic Heart Failure in the Adult
January 2006

2. Supported by Medtronic, Inc.
Medtronic, Inc. was not involved in the development of this
slide deck and in no way influenced its contents.

3. Writing Committee Members Sharon Ann Hunt, MD, FACC, FAHA, Chair
ACC/AHA 2005 Guideline Update for the Management of Patients With Chronic Heart Failure in the Adult
Writing Committee Members
Sharon Ann Hunt, MD, FACC, FAHA, Chair
William T. Abraham, MD, FACC, FAHA
Marshall H. Chin, MD, MPH, FACP
Arthur M. Feldman, MD, PhD, FACC, FAHA
Gary S. Francis, MD, FACC, FAHA
Theodore G. Ganiats, MD
Mariell Jessup, MD, FACC, FAHA
Marvin A. Konstam, MD, FACC
Donna M. Mancini, MD
Keith Michl, MD, FACP
John A. Oates, MD, FAHA
Peter S. Rahko, MD, FACC, FAHA
Marc A. Silver, MD, FACC, FAHA
Lynne Warner Stevenson, MD, FACC, FAHA
Clyde W. Yancy, MD, FACC, FAHA

4. Applying Classification of Recommendations and Level of Evidence
Class I Benefit >>> Risk
Procedure/ Treatment SHOULD be performed/ administered
Class IIa Benefit >> Risk Additional studies with focused objectives needed
IT IS REASONABLE to perform procedure/administer treatment
Class IIb Benefit ≥ Risk Additional studies with broad objectives needed; Additional registry data would be helpful
Procedure/Treatment
MAY BE CONSIDERED
Class III
Risk ≥ Benefit No additional studies needed
Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL
should
is recommended
is indicated
is useful/effective/ beneficial
is reasonable
can be useful/effective/ beneficial
is probably recommended or indicated
may/might be considered
may/might be reasonable
usefulness/effectiveness is unknown /unclear/uncertain or not well established
is not recommended
is not indicated
should not
is not useful/effective/beneficial
may be harmful

5. Applying Classification of Recommendations and Level of Evidence
Level A
Multiple (3-5) population risk strata evaluated
General consistency of direction and magnitude of effect
Class I
• Recommen-dation that procedure or treatment is useful/ effective
• Sufficient evidence from multiple randomized trials or meta-analyses
Class IIa
• Recommen-dation in favor of treatment or procedure being useful/ effective
• Some conflicting evidence from multiple randomized trials or meta-analyses
Class IIb
• Recommen-dation’s usefulness/ efficacy less well established
• Greater conflicting evidence from multiple randomized trials or meta-analyses
Class III
• Recommen-dation that procedure or treatment not useful/effective and may be harmful

6. Applying Classification of Recommendations and Level of Evidence
Level B
Limited (2-3) population risk strata evaluated
Class I
• Recommen-dation that procedure or treatment is useful/effective
• Limited evidence from single randomized trial or non-randomized studies
Class IIa
• Recommen-dation in favor of treatment or procedure being useful/ effective
• Some conflicting evidence from single randomized trial or non-randomized studies
Class IIb
• Recommen-dation’s usefulness/ efficacy less well established
• Greater conflicting evidence from single randomized trial or non-randomized studies
Class III
• Recommen-dation that procedure or treatment not useful/effective and may be harmful

7. Applying Classification of Recommendations and Level of Evidence
Level C Very limited (1-2) population risk strata evaluated
Class I
• Recommen-dation that procedure or treatment is useful/ effective
• Only expert opinion, case studies, or standard-of-care
Class IIa
• Recommen-dation in favor of treatment or procedure being useful/effective
• Only diverging expert opinion, case studies, or standard-of-care
Class IIb
• Recommen-dation’s usefulness/ efficacy less well established
Class III
• Recommend-ation that procedure or treatment not useful/effective and may be harmful

8. Heart Failure is a Major and Growing Public Health Problem in the U.S.
Approximately 5 million patients in this country have HF
Over 550,000 patients are diagnosed with HF for the first time each year
Primary reason for 12 to 15 million office visits and 6.5 million hospital days each year
In 2001, nearly 53,000 patients died of HF as a primary cause

9. Heart Failure is Primarily a Condition of the Elderly
The incidence of HF approaches 10 per 1000 population after age 65
HF is the most common Medicare diagnosis-related group
More dollars are spent for the diagnosis and treatment of HF than any other diagnosis by Medicare

10. Guideline Scope Document focuses on : Prevention of HF
Diagnosis and management of
chronic HF in the adult

11. Definition of Heart Failure
HF is a complex clinical syndrome that can
result from any structural or functional
cardiac disorder that impairs the ability of
the ventricle to fill with or eject blood.

12. “Heart Failure” vs. “Congestive Heart Failure”
Because not all patients have volume overload at
the time of initial or subsequent evaluation, the
term “heart failure” is preferred over the older
term “congestive heart failure.”

13. Causes of HF in Western World
For a substantial proportion of patients, causes are:
Coronary artery disease
Hypertension
Dilated cardiomyopathy

15. Stages of Heart Failure
At Risk for Heart Failure:
STAGE A High risk for developing HF
STAGE B Asymptomatic LV dysfunction
Heart Failure:
STAGE C Past or current symptoms of HF
STAGE D End-stage HF

16. Stages of Heart Failure
Designed to emphasize preventability of HF
Designed to recognize the progressive nature of LV dysfunction

17. Stages of Heart Failure COMPLEMENT, DO NOT REPLACE NYHA CLASSES
NYHA Classes - shift back/forth in individual patient (in response to Rx and/or progression of disease)
Stages - progress in one direction due to cardiac remodeling

22. Patients at High Risk for Developing Heart Failure
Stage A
Patients at High Risk for
Developing Heart Failure

23. Stage A Therapy Recommended Therapies to Reduce Risk Include:
Treating known risk factors (hypertension, diabetes, etc.)
with therapy consistent with contemporary guidelines
Avoiding behaviors increasing risk (i.e., smoking
excessive consumption of alcohol, illicit drug use)
Periodic evaluation for signs and symptoms of HF
Ventricular rate control or sinus rhythm restoration
Noninvasive evaluation of LV function
Drug therapy –
Angiotensin Converting Enzyme Inhibitors (ACEI)
Angiotensin Receptor Blockers (ARBs)

24. Using Therapy Consistent with Contemporary Guidelines
Stage A Therapy
Using Therapy Consistent with
Contemporary Guidelines
In patients at high risk for developing HF,
systolic and diastolic hypertension should be
controlled in accordance with contemporary
guidelines.
In patients at high risk for developing HF, lipid
disorders should be treated in accordance
with contemporary guidelines.

25. Using Therapy Consistent with Contemporary Guidelines
Stage A Therapy
Using Therapy Consistent with
Contemporary Guidelines
In patients at high risk for developing HF who
have known atherosclerotic vascular disease,
healthcare providers should follow current
guidelines for secondary prevention.
For patients with diabetes mellitus (who are all
at high risk for developing HF), blood sugar
should be controlled in accordance with
contemporary guidelines.

26. Using Therapy Consistent with Contemporary Guidelines
Stage A Therapy
Using Therapy Consistent with
Contemporary Guidelines
Thyroid disorders should be treated in
accordance with contemporary guidelines in
patients at high risk for developing HF.

27. Avoiding Behaviors That Increase Risk
Stage A Therapy
Avoiding Behaviors That
Increase Risk
Patients at high risk for developing HF should
be counseled to avoid behaviors that may
increase the risk of HF (e.g., smoking,
excessive alcohol consumption, and illicit
drug use).

28. Periodic Evaluation for Signs and Symptoms
Stage A Therapy
Periodic Evaluation for
Signs and Symptoms
Healthcare providers should perform periodic
evaluation for signs and symptoms of HF in
patients at high risk for developing HF.

29. B Stage A Therapy Ventricular Rate Control or Sinus Rhythm Restoration
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIa
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
IIb
III
III
III
III
III
III
III
III
III
III
III
III
Ventricular rate should be controlled or sinus
rhythm restored in patients with
supraventricular tachyarrhythmias who are at
high risk for developing HF. B

30. Noninvasive Evaluation of LV Function
Stage A Therapy
Noninvasive Evaluation of
LV Function
Healthcare providers should perform a
noninvasive evaluation of LV function (i.e.,
LVEF) in patients with a strong family history
of cardiomyopathy or in those receiving
cardiotoxic interventions.

31. A Stage A Therapy Angiotensin Converting Enzyme Inhibitors (ACEI)
IIa
IIb
III A
ACEI can be useful to prevent HF in patients at
high risk for developing HF who have a history of
atherosclerotic vascular disease, diabetes
mellitus, or hypertension with associated
cardiovascular risk factors.

32. C Stage A Therapy Angiotension Receptor Blockers (ARBs)
ARBs can be useful to prevent HF in patients
at high risk for developing HF who have a
history of atherosclerotic vascular disease,
diabetes mellitus, or hypertension with
associated cardiovascular risk factors. I
IIa
IIb
III C

33. Therapies NOT Recommended
Stage A Therapy
Therapies NOT Recommended
Routine use of nutritional supplements solely
to prevent the development of structural heart
disease should not be recommended for
patients at high risk for developing HF.

34. Patients with Asymptomatic
Stage B
Patients with Asymptomatic
LV Dysfunction

35. Stage B Therapy Recommended Therapies:
General Measures as advised for Stage A
Drug therapy for all patients
ACEI or ARBs
Beta-Blockers
ICDs in appropriate patients
Coronary revascularization in appropriate patients
Valve replacement or repair in appropriate patients

36. Stage B Therapy General Measures
All Class I recommendations for Stage A
should apply to patients with cardiac
structural abnormalities who have not
developed HF. (Levels of Evidence: A, B, and
C as appropriate)
Patients who have not developed HF
symptoms should be treated according to
contemporary guidelines after an acute MI. I
IIa
IIb
III

37. B Stage B Therapy Angiotensin Converting Enzyme Inhibitors (ACEI)
Beta-blockers and ACEIs should be used in all
patients with a recent or remote history of MI
regardless of EF or presence of HF.
ACEI should be used in patients with a reduced EF
and no symptoms of HF, even if they have not
experienced MI.
ACEI or ARBs can be beneficial in patients with
hypertension and LVH and no symptoms of HF. I
IIa
IIb
III B

38. B B C Stage B Therapy Angiotensin Receptor Blockers (ARBs)
IIa
IIb
III B
An ARB should be administered to post-MI patients
without HF who are intolerant of ACEIs and have a
low LVEF.
ACEIs or ARBs can be beneficial in patients with
hypertension and LVH and no symptoms of HF.
ARBs can be beneficial in patients with low EF and
no symptoms of HF who are intolerant of ACEIs. I
IIa
IIb
III B I
IIa
IIb
III C

39. Stage B Therapy Beta-Blockers
Beta-blockers and ACEIs should be used in all
patients with a recent or remote history of MI
regardless of EF or presence of HF.
Beta-blockers are indicated in all patients
without a history of MI who have a reduced
LVEF with no HF symptoms.

40. B Stage B Therapy Internal Cardioverter Defibrillator (ICD)
IIa
IIb
III B
Placement of an ICD is reasonable in patients with
ischemic cardiomyopathy who are at least 40 days
post-MI, have an LVEF of 30% or less, are NYHA
functional class I on chronic optimal medical therapy,
and have reasonable expectation of survival with a
good functional status for more than 1 year.
Placement of an ICD might be considered in patients
without HF who have nonischemic cardiomyopathy
and an LVEF less than or equal to 30% who are in
NYHA functional class I with chronic optimal medical
therapy and have a reasonable expectation of survival
with good functional status for more than 1 year.

41. Coronary Revascularization
Stage B Therapy
Coronary Revascularization
Coronary revascularization should be
recommended in appropriate patients
without symptoms of HF in accordance
with contemporary guidelines (see
ACC/AHA Guidelines for the Management
of Patients With Chronic Stable Angina).

42. B Stage B Therapy Valve Replacement/Repair
IIa
IIb
III B
Valve replacement or repair should be
recommended for patients with
hemodynamically significant valvular
stenosis or regurgitation and no
symptoms of HF in accordance with
contemporary guidelines.

43. Therapies NOT Recommended
Stage B Therapy
Therapies NOT Recommended
Digoxin should not be used in patients with low EF,
sinus rhythm, and no history of HF symptoms,
because in this population, the risk of harm is not
balanced by any known benefit.
Use of nutritional supplements to treat structural
heart disease or to prevent the development of
symptoms of HF is not recommended.
Calcium channel blockers with negative inotropic
effects may be harmful in asymptomatic patients
with low LVEF and no symptoms of HF after MI.

44. Patients with Past or Current Symptoms of Heart Failure
Stage C
Patients with Past or Current
Symptoms of Heart Failure

45. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Recommended Therapies:
General measures as advised for Stages A and B
Drug therapy for all patients
Diuretics for fluid retention
ACEI
Beta-blockers
Drug therapy for selected patients
Aldosterone Antagonists
ARBs
Digitalis
Hydralazine/nitrates
ICDs in appropriate patients
Cardiac resynchronization in appropriate patients
Exercise Testing and Training

46. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
General Measures
Measures listed as Class I recommendations for
patients in stages A and B are also appropriate for
patients in Stage C. (Levels of Evidence: A, B, and C as
appropriate)
Drugs known to adversely affect the clinical status of
patients with current or prior symptoms of HF and
reduced LVEF should be avoided or withdrawn
whenever possible (e.g., nonsteroidal anti-inflammatory
drugs, most antiarrhythmic drugs, and most calcium
channel blocking drugs). I
IIa
IIb
III I
IIa
IIb
III B

47. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Diuretics
Diuretics and salt restriction are indicated in
patients with current or prior symptoms of HF
and reduced LVEF who have evidence of fluid
retention.

48. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Angiotensin Enzyme Converting
Inhibitors (ACEIs)
ACEIs are recommended for all patients with
current or prior symptoms of HF and reduced
LVEF, unless contraindicated.
Routine combined use of an ACEI, ARB, and
aldosterone antagonist is not recommended for
patients with current or prior symptoms of HF
and reduced LVEF.

49. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Angiotensin Receptor Blockers (ARBs)
ARBs approved for the treatment of HF are
recommended in patients with current or prior
symptoms of HF and reduced LVEF who are ACEI-
intolerant (see full text guidelines for information
regarding patients with angioedema).
ARBs are reasonable to use as alternatives to ACEIs
as first-line therapy for patients with mild to
moderate HF and reduced LVEF, especially for
patients already taking ARBs for other indications. I
IIa
IIb
III A

50. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
ARBs (cont’d)
The addition of an ARB may be considered in
persistently symptomatic patients with reduced
LVEF who are already being treated with
conventional therapy.
Routine combined use of an ACEI, ARB, and
aldosterone antagonist is not recommended for
patientswith current or prior symptoms of HF and
reduced LVEF.

51. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Aldosterone Antagonists
Addition of an aldosterone antagonist is recommended in
selected patients with moderately severe to severe
symptoms of HF and reduced LVEF who can be
carefully monitored for preserved renal function and
normal potassium concentration. Creatinine should be
less than or equal to 2.5 mg/dL in men or less than or
equal to 2.0 mg/dL in women and potassium should be
less than 5.0 mEq/L. Under circumstances where
monitoring for hyperkalemia or renal dysfunction is not
anticipated to be feasible, the risks may outweigh the
benefits of aldosterone antagonists.
Routine combined use of an ACEI, ARB, and aldosterone
antagonist is not recommended for patients with current
or prior symptoms of HF and reduced LVEF. I
IIa
IIb
III B

52. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Beta-Blockers
Beta-blockers (using 1 of the 3 proven to reduce
mortality, i.e., bisoprolol, carvedilol, and sustained
release metoprolol succinate) are recommended for
all stable patients with current or prior symptoms of
HF and reduced LVEF, unless contraindicated.

55. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Digitalis I
IIa
IIb
III B
Digitalis can be beneficial in patients with
current or prior symptoms of HF and reduced
LVEF to decrease hospitalizations for HF.

56. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Hydralazine and Isosorbide Dinitrate I
IIa
IIb
III B
The addition of a combination of hydralazine and a
nitrate is reasonable for patients with reduced
LVEF who are already taking an ACEI and beta-
blocker for symptomatic HF and who have
persistent symptoms.
A combination of hydralazine and a nitrate might be
reasonable in patients with current or prior
symptoms of HF and reduced LVEF who cannot be
given an ACEI or ARB because of drug intolerance,
hypotension, or renal insufficiency.

57. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Implantable Cardioverter-
Defibrillators (ICDs)
An ICD is recommended as secondary prevention to
prolong survival in patients with current or prior
symptoms of HF and reduced LVEF who have a history of
cardiac arrest, ventricular fibrillation, or hemodynamically
destabilizing ventricular tachycardia.
ICD therapy is recommended for primary prevention to
reduce total mortality by a reduction in sudden cardiac
death in patients with ischemic heart disease who are at
least 40 days post-MI, have an LVEF less than or equal to
30%, with NYHA functional class II or III symptoms while
undergoing chronic optimal medical therapy, and have
reasonable expectation of survival with a good functional
status for more than 1 year.

58. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
ICDs (cont’d) I
IIa
IIb
III B
ICD therapy is recommended for primary prevention to
reduce total mortality by a reduction in sudden cardiac
death in patients with nonischemic cardiomyopathy who
have an LVEF less than or equal to 30%, with NYHA
functional class II or III symptoms while undergoing
chronic optimal medical therapy, and who have
reasonable expectation of survival with a good functional
status for more than 1 year.
Placement of an ICD is reasonable in patients with LVEF
of 30% to 35% of any origin with NYHA functional class II
or III symptoms who are taking chronic optimal medical
therapy and who have reasonable expectation of survival
with good functional status of more than 1 year. I
IIa
IIb
III B

59. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Cardiac Resynchronization
Patients with LVEF less than or equal to 35%, sinus
rhythm, and NYHA functional class III or ambulatory
class IV symptoms despite recommended, optimal
medical therapy and who have cardiac
dyssynchrony, which is currently defined as a QRS
duration greater than 120 ms, should receive cardiac
resynchronization therapy unless contraindicated.

60. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Exercise Testing and Training
Maximal exercise testing with or without
measurement of respiratory gas exchange is
recommended to facilitate prescription of an
appropriate exercise program for patients
presenting with HF.
Exercise training is beneficial as an adjunctive
approach to improve clinical status in ambulatory
patients with current or prior symptoms of HF and
reduced LVEF. I
IIa
IIb
III B

61. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Unproven/Not Recommended
Drugs and Interventions for HF
Nutritional Supplements
Hormonal Therapies
Intermittent Intravenous
Positive Inotropic Therapy

62. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Unproven/Not Recommended Drugs and Interventions
Long-term use of an infusion of a positive inotropic
drug may be harmful and is not recommended for
patients with current or prior symptoms of HF and
reduced LVEF, except as palliation for patients with
end-stage disease who cannot be stabilized with
standard medical treatment (see recommendations
for Stage D).
Use of nutritional supplements as treatment for HF
is not indicated in patients with current or prior
symptoms of HF and reduced LVEF.

63. (Reduced LVEF with Symptoms)
Stage C Therapy
(Reduced LVEF with Symptoms)
Unproven/Not Recommended Drugs and Interventions
Calcium channel blocking drugs are not indicated as
routine treatment for HF in patients with current or
prior symptoms of HF and reduced LVEF.
Hormonal therapies other than to replete
deficiencies are not recommended and may be
harmful to patients with current or prior symptoms
of HF and reduced LVEF.
Routine combined use of an ACEI, ARB, and
aldosterone antagonist is not recommended for
patientswith current or prior symptoms of HF and
reduced LVEF.

64. (Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Recommended Therapies for Routine Use:
Treating known risk factor (hypertension) with therapy
consistent with contemporary guidelines
Ventricular rate control for all patients
Drugs for all patients -
Diuretics
Drugs for appropriate patients –
ACEI
ARBs
Beta-Blockers
Digitalis
Coronary revascularization in selected patients
Restoration/maintenance of sinus rhythm in
appropriate patients

65. Differential Diagnosis in Patient with HF and Normal LVEF with Symptoms
Incorrect diagnosis of HF
Inaccurate measurement of LVEF
Primary valvular disease
Restrictive (infiltrative) cardiomyopathies
Amyloidosis, sarcoidosis, hemochromatosis
Pericardial constriction
Episodic or reversible LV systolic dysfunction
Severe hypertension, myocardial ischemia
HF associated with high metabolic demand (high-output states)
Anemia, thyrotoxicosis, arteriovenous fistulae
Chronic pulmonary disease with right HF
Pulmonary hypertension associated with pulmonary vascular disorders
Atrial myxoma
Diastolic dysfunction of uncertain origin
Obesity

66. (Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Treating known risk factors - Hypertension
Physicians should control systolic and
diastolic hypertension in patients with HF and
normal LVEF, in accordance with published
guidelines.

67. (Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Ventricular Rate Control
Physicians should control ventricular rate in
patients with HF and normal LVEF and atrial
fibrillation.

68. (Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Diuretics
Physicians should use diuretics to control
pulmonary congestion and peripheral edema in
patients with HF and normal LVEF.

69. (Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Coronary Revascularization
Coronary revascularization is reasonable in
patients with HF and normal LVEF and
coronary artery disease in whom symptomatic
or demonstrable myocardial ischemia is
judged to be having an adverse effect on
cardiac function. I
IIa
IIb
III C

70. (Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Restoration/Maintenance
of Sinus Rhythm I
IIa
IIb
III
Restoration and maintenance of sinus rhythm
in patients with atrial fibrillation and HF and
normal LVEF might be useful to improve
symptoms.

71. (Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Angiotensin Enzyme Converting
Inhibitors (ACEIs) I
IIa
IIb
III
The use of beta-adrenergic blocking agents, ACEIs,
ARBs, or calcium antagonists in patients with HF
and normal LVEF and controlled hypertension might
be effective to minimize symptoms of HF.

72. (Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Angiotensin Receptor Blockers (ARBs)
The use of beta-adrenergic blocking agents, ACEIs,
ARBs, or calcium antagonists in patients with HF
and normal LVEF and controlled hypertension might
be effective to minimize symptoms of HF. I
IIa
IIb
III

73. (Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Beta-Blockers I
IIa
IIb
III
The use of beta-adrenergic blocking agents, ACEIs,
ARBs, or calcium antagonists in patients with HF
and normal LVEF and controlled hypertension might
be effective to minimize symptoms of HF.

74. (Normal LVEF with Symptoms)
Stage C Therapy
(Normal LVEF with Symptoms)
Digitalis
The usefulness of digitalis to minimize
symptoms of HF in patients with HF and normal
LVEF is not well established. I
IIa
IIb
III

75. Patients with Refractory End-Stage HF
Stage D
Patients with Refractory End-Stage HF

76. Stage D Therapy Recommended Therapies Include:
Control of fluid retention
Referral to a HF program for appropriate pts
Discussion of options for end-of-life care
Informing re: option to inactivate defibrillator
Device use in appropriate patients
Surgical therapy –
Cardiac transplantation
Mitral valve repair or replacement
Other
Drug Therapy –
Positive inotrope infusion as palliation
in appropriate patients

77. B Stage D Therapy Control of Fluid Retention
IIa
IIb
III B
Meticulous identification and control of fluid
retention is recommended in patients with
refractory end-stage HF.

78. Referral to an HF Program
Stage D Therapy
Referral to an HF Program
Referral of patients with refractory end-stage
HF to an HF program with expertise in the
management of refractory HF is useful.

79. Discussion of Options for End-of-Life Care
Stage D Therapy
Discussion of Options for
End-of-Life Care
Options for end-of-life care should be
discussed with the patient and family when
severe symptoms in patients with refractory
end-stage HF persist despite application of all
recommended therapies.

80. inactivate defibrillation
Stage D Therapy
Inform on option to
inactivate defibrillation
Patients with refractory end-stage HF and
implantable defibrillators should receive
information about the option to inactivate
defibrillation.

81. B Stage D Therapy Surgical Therapy
IIa
IIb
III B
Referral for cardiac transplantation in
potentially eligible patients is recommended for
patients with refractory end-stage HF.
The effectiveness of mitral valve repair or
replacement is not established for severe
secondary mitral regurgitation in refractory
end-stage HF.

82. B Stage D Therapy Device Use Consideration of an LV assist device as
IIa
IIb
III B
Consideration of an LV assist device as
permanentor “destination” therapy is
reasonable in highly selected patients with
refractory end-stage HF and an estimated
1-year mortality over 50% with medical therapy.
Pulmonary artery catheter placement may be
reasonable to guide therapy in patients with
refractory end-stage HF and persistently severe
symptoms.

83. Stage D Therapy Medical Therapy
Continuous intravenous infusion of a positive
inotropic agent may be considered for
palliation of symptoms in patients with
refractory end-stage HF.
Routine intermittent infusions of positive
inotropic agents are not recommended for
patients with refractory end-stage HF.

84. Therapies NOT Recommended
Stage D Therapy
Therapies NOT Recommended
Partial left ventriculectomy is not
recommended inpatients with nonischemic
cardiomyopathy and refractory end-stage HF.
Routine intermittent infusions of positive
inotropic agents are not recommended for
patients with refractory end-stage HF.