The Heart Failure Society of America, along with the American Heart Association and the American College of Cardiology, today released an updated guideline for the management of heart failure.

The guideline update extends the prior guideline update released May 20, 2016 addressing new pharmacological therapy for heart failure. This guideline update includes revision to the sections on biomarkers, including recommendations for the prevention, diagnosis, and prevention or added risk stratification of heart failure; updates on heart failure with preserved ejection fraction; new data on important comorbidities including sleep apnea, anemia and hypertension; and new insights regarding the prevention of heart failure.

“For clinical practice guidelines to be truly useful, new evidence that changes clinical practice should be rapidly incorporated in the guidelines and disseminated to the practice community. These updates were deemed necessary as new evidence in all of the areas addressed, derived from clinical trials, has emerged since the 2013 Heart Failure Guidelines and now merits inclusion,” said Clyde W. Yancy, MD, MSc, MACC, FAHA, FHFSA, chair of the writing group for the document.

Revisions to the biomarkers section include:

• For Prevention: Class IIa recommendation (Level of Evidence: B-R) for utilizing natriuretic peptide biomarker-based screening for those at risk of developing heart failure, followed by team-based care including a cardiovascular specialist optimizing guideline-directed medical therapy, to prevent the development of left ventricular dysfunction or new-onset heart failure.
• For Diagnosis: Class I recommendation (Level of Evidence: A) for measurement of natriuretic peptide biomarkers in patients presenting with dyspnea, to support a diagnosis or exclusion of heart failure.
• For Prognosis or Added Risk Stratification:
  • Class I recommendation (Level of Evidence: A) for measurement of B-type natriuretic peptide or N-terminal pro-B-type natriuretic peptide for establishing prognosis or disease severity in chronic heart failure.
  • Class I recommendation (Level of Evidence: A) for measurement of baseline natriuretic peptide biomarkers and/or cardiac troponin on admission to the hospital to establish a prognosis in acutely decompensated heart failure.
  • Class IIa recommendation (Level of Evidence: B-NR) for measurement of a predischarge natriuretic peptide level during a heart failure hospitalization, to establish a post-discharge prognosis
  • Class IIb recommendation (Level of Evidence: B-NR) for measurement of other clinically available tests, such as biomarkers of myocardial injury or fibrosis, in patients with chronic heart failure for additive risk stratification.

Revisions to the section on Stage C heart failure with preserved ejection fraction include:

• Class IIb recommendation (Level of Evidence: B-R) for use of aldosterone antagonists in appropriately selected patients with heart failure with preserved ejection fraction (with ejection fraction ≥45 percent, elevated B-type natriuretic peptide or heart failure admission within one year, estimated glomerular filtration rate >30 and creatinine <2.5 mg/dL, potassium <5.0 mEq /L), to decrease hospitalizations.
• Class III recommendation: (Level of Evidence: B-R) for routine use of nitrates or phosphodiesterase-5 inhibitors to increase quality of life or outcomes in patients with heart failure with preserved ejection fraction, as there is no benefit.

Revisions to the section on comorbidities include:

• Anemia:
  • Class IIb recommendation (Level of Evidence: B-R) for intravenous iron replacement in patients with NYHA class II and III heart failure and iron deficiency (ferritin <100 ng/mL or 100 to 300 ng/mL if transferrin saturation <20 percent), to improve functional status and quality of life.
  • Class III recommendation: (Level of Evidence: B-R) that erythropoietin stimulating agents should not be used in patients with heart failure and anemia to improve morbidity and mortality, as there is no benefit
• Hypertension:
  • Class I recommendation (Level of Evidence: B-R) for targeting an optimal blood pressure of less than 130/80 mm Hg in those with hypertension and at increased risk (stage A heart failure).
  • Class I recommendation (Level of Evidence: C-EO) for titration of guideline-directed medical therapy to attain systolic blood pressure <130 mm Hg in patients with heart failure with reduced ejection fraction and hypertension.
  • Class I recommendation (Level of Evidence: C-LD) for titration of guideline-directed medical therapy to attain systolic blood pressure <130 mm Hg in patients with heart failure with preserved ejection fraction and persistent hypertension after management of volume overload.
• Sleep Disordered Breathing:
  • Class IIa recommendation (Level of Evidence: C-LD) for a formal sleep assessment in patients with NYHA class II–IV heart failure and suspicion of sleep disordered breathing or excessive daytime sleepiness.
  • Class IIb recommendation (Level of Evidence: B-R) for utilization of continuous positive airway pressure in patients with cardiovascular disease and obstructive sleep apnea, to improve sleep quality and daytime sleepiness.
  • Class III recommendation: Harm (Level of Evidence: B-R) for use of adaptive servo-ventilation in patients with NYHA class II–IV heart failure with reduced ejection fraction and central sleep apnea as it causes harm.

This updated guideline is the second of a two-stage publication. Part one was published as the 2016 ACC/AHA/HFSA Focused Update on New Pharmacological Therapy for Heart Failure, which introduced guidance on new therapies, specifically for the use of an angiotensin receptor–neprilysin inhibitor (ARNI) (valsartan/sacubitril) and a sinoatrial node modulator (ivabradine). The 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure will publish online today in the Journal of Cardiac Failure, Journal of the American College of Cardiology, and Circulation. Both updates represent a new model in the generation of heart failure clinical practice guidelines that now includes the Heart Failure Society of America., American College of Cardiology, and the American Heart Association.