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New Heart Failure Guidelines Emphasize Early Diagnosis and Treatment
The document is available today on the Web sites of the ACC (www.acc.org) and the AHA (www.americanheart.org) and will be published in the Sept. 20, 2005, issues of the Journal of the American College of Cardiology, and Circulation: Journal of the American Heart Association along with the ACC/AHA Clinical Performance Measures for Adults with Chronic Heart Failure and the ACC/AHA Key Data Elements and Definitions for Measuring Clinical Measurements and Outcomes of Patients with Chronic Heart Failure.
Noting that new treatment approaches may also improve the quality of life for patients, the authors classified heart failure on a scale from risk factors to end-stage disease:
* Stages A and B are when patients lack early signs or symptoms of heart failure, but are at risk because of risk factors or heart abnormalities, which could include a change in the shape or structure of the heart.
* Stage C denotes patients with current or past heart failure symptoms such as shortness of breath.
* Stage D designates patients with refractory heart failure who might be eligible for specialized advanced treatment — including cardiac transplantation — or compassionate end-of-life care such as hospice.
Nearly any form of heart disease may ultimately lead to heart failure. The guidelines stress that early recognition and proper treatment of high blood pressure, diabetes, coronary artery disease and other cardiovascular risk factors can help patients delay or avoid heart failure.
The key to prevention is to get the risk factors under control. For instance, studies have shown controlling hypertension can reduce the incidence of heart failure by 50 percent.
“More treatments have made our decision-making far more complex since the last ACC/AHA heart failure guidelines only four years ago,” said Sharon Ann Hunt, M.D., F.A.C.C., professor of cardiovascular medicine at Stanford University Medical Center and chair of the writing group.
From 1990-99, the number of people hospitalized with a primary diagnosis of heart failure increased from 810,000 to more than 1 million. This was due to the population aging and to more people surviving heart attacks. Heart failure mostly affects the elderly, and more Medicare dollars are spent for heart failure diagnosis and treatment than for any other disease.
About 5 million U.S. residents are living with heart failure, and more than 550,000 people are diagnosed with the condition each year. In 2005 the disease will cost an estimated $27.9 billion in direct and indirect health care expenses, the authors write.
Some people may not realize one of the main symptoms of heart failure is becoming easily exhausted.
“We know there are many people walking around who think they are just out of shape or that they are just getting older, or that their ankles are swelling because it’s hot,” said co-author Mariell Jessup, M.D., F.A.C.C., medical director of the heart failure and cardiac transplantation program and professor of medicine at the University of Pennsylvania Medical Center in Philadelphia. “They don’t appreciate that this may be due to heart failure.”
The guidelines also change the name of the condition from congestive heart failure (CHF) to heart failure (HF) to reflect the broad spectrum of the disease. Congestion occurs when the heart cannot efficiently pump or eject blood from its chambers. This causes fluid build-up in the lungs and heart, resulting in stiff, fluid-filled lungs and shortness of breath. The panel dropped the word ‘congestive’ because people can have few or no symptoms of congestion, and still have a severely abnormal heart with symptoms of fatigue and exercise intolerance caused by poor cardiac output, Jessup said.
In recent years, doctors have recognized that many people with normal ejection fraction have heart failure. This often occurs because the heart pumps properly, but fails to fill adequately with blood, a condition called diastolic heart failure. These patients rarely have been included in clinical trials of new drugs and devices in the past, but they are the subjects of several new, ongoing trials. These trials should help settle the issue of whether their treatment should be the same as that for patients with reduced ejection fraction.
“The second major point is that heart failure does not go away,” Jessup said. “There are drugs that need to be used and medical care that needs to be done on a regular basis.”
The committee also recommended left ventricular assist devices (LVADs) be considered as permanent or “destination” therapy in selected patients.
LVADs are implanted mechanical devices that help pump blood through the heart and can be used as a reasonable permanent therapy in some end-stage heart failure patients who are not candidates for transplants, don’t respond to standard treatment and have a one-year survival outlook of less than 50 percent. The devices, which recently received U.S. Food and Drug Administration approval as permanent or “destination” therapy, were first used as a temporary measure to keep patients alive while awaiting a heart transplant. “It’s going to be a whole new era in treating heart failure,” Jessup said. “Eventually, we’ll have portable artificial pumps that can take over the action of the heart.”
* Expand the number of patients eligible for implantable cardioverter-defibrillators (ICDs), devices implanted under the skin that save lives by shocking chaotic heart rhythms back into a healthy pattern.1
* Provide information on end-of-life issues. Although treatment advances can extend lives, heart failure is often fatal. The guidelines recommend that cardiologists broach the subject of hospice care — support and comfort for dying patients and their families.
“There is a failure to recognize that end-stage heart failure patients frequently come in and out of the hospital over and over again and suffer a lot with really no impact on their ultimate survival,” Jessup said. “I think using hospice is a way of improving the remaining days that these patients have. Hospice can be a very positive experience for patients and their families.”
She acknowledged that this represents a new role for many cardiologists.
“Cardiologists aren’t used to talking about hospice. They are more used to doing interventions. So it is a big shift,” she said.
The guidelines also suggest that a new perspective on treating end-stage heart failure could result in a smoother, less stressful transition for patients and their families.
Co-authors and members of the Heart Failure Guidelines Writing Committee: William T. Abraham, M.D., F.A.C.C.; Marshall H. Chin, M.D., M.P.H.; Arthur M. Feldman, M.D., Ph.D. F.A.C.C.; Gary S. Francis, M.D., F.A.C.C.; Theodore G. Ganiats, M.D.; Marvin A. Konstam, M.D., F.A.C.C.; Donna M. Mancini, M.D.; Keith Michl, M.D.; John A. Oates, M.D.; Peter S. Rahko, M.D., F.A.C.C.; Marc A. Silver, M.D., F.A.C.C.; Lynne Warner Stevenson, M.D., F.A.C.C; and Clyde W. Yancy, M.D., F.A.C.C.
Other organizations that participated in the development of the guidelines were the American Academy of Family Physicians, the American College of Physicians, the American College of Chest Physicians, the Heart Failure Society of America and the International Society for Heart and Lung Transplantation.
1 Editor’s note: The final version of these guidelines have further expanded the number of patients who should be considered for ICDs, by adding the recommendation that patients with ischemic cardiomyopathy, functional class 1 with low ejection fraction be considered for ICD placement (MADIT II trial).
Editor’s note: The American Heart Association has many heart failure tools and resources to assist patients, caregivers and healthcare providers available through americanheart.org/heartfailure.
Source: American College of Cardiology