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2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation Sharon Ann Hunt, William T. Abraham, Marshall H. Chin, Arthur M. Feldman, Gary S. Francis, Theodore G. Ganiats, Mariell Jessup, Marvin A. Konstam, Donna M. Mancini, Keith Michl, John A. Oates, Peter S. Rahko, Marc A. Silver, Lynne Warner Stevenson, and Clyde W. Yancy J. Am. Coll. Cardiol. 2009;53;e1-e90; originally published online Mar 26, 2009; doi:10.1016/j.jacc.2008.11.013 This information is current as of April 20, 2009 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://content.onlinejacc.org/cgi/content/full/53/15/e1 Downloaded from content.onlinejacc.org by on April 20, 2009 Journal of the American College of Cardiology Vol. 53, No. 15, 2009 © 2009 by the American College of Cardiology Foundation and the American Heart Association, Inc. ISSN 0735-1097/09/$36.00 Published by Elsevier Inc. doi:10.1016/j.jacc.2008.11.013 PRACTICE GUIDELINE: FULL TEXT 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation 2005 Writing Sharon Ann Hunt, MD, FACC, FAHA, Chair Marvin A. Konstam, MD, FACC Committee Donna M. Mancini, MD Members William T. Abraham, MD, FACC, FAHA Keith Michl, MD, FACP Marshall H. Chin, MD, MPH, FACP John A. Oates, MD, FAHA Arthur M. Feldman, MD, PHD, FACC, FAHA Peter S. Rahko, MD, FACC, FAHA Gary S. Francis, MD, FACC, FAHA Marc A. Silver, MD, FACC, FAHA Theodore G. Ganiats, MD Lynne Warner Stevenson, MD, FACC, FAHA Mariell Jessup, MD, FACC, FAHA Clyde W. Yancy, MD, FACC, FAHA 2009 Mariell Jessup, MD, FACC, FAHA, Chair* Lynne Warner Stevenson, MD, FACC, FAHA† Focused Clyde W. Yancy, MD, FACC, FAHA†† Update Writing William T. Abraham, MD, FACC, FAHA† Group Donald E. Casey, MD, MPH, MBA‡ *International Society for Heart and Lung Transplantation Represen- tative; †American College of Cardiology Foundation/American Heart Members Arthur M. Feldman, MD, PHD, FACC, FAHA§ Association Representative; ‡American College of Physicians Repre- ʈ Gary S. Francis, MD, FACC, FAHA§ sentative; §Heart Failure Society of America Representative; American ʈ Academy of Family Physicians Representative; ¶American College of Theodore G. Ganiats, MD Cardiology Foundation/American Heart Association Performance Marvin A. Konstam, MD, FACC¶ Measures Liaison; #Content Expert; **American College of Chest Physicians Representative; ††American College of Cardiology Founda- Donna M. Mancini, MD# tion/American Heart Association Task Force on Practice Guidelines Peter S. Rahko, MD, FACC, FAHA† Liaison Marc A. Silver, MD, FACC, FAHA** This document was approved by the American College of Cardiology Foundation This article has been copublished electronically by Circulation. Board of Trustees and the American Heart Association Science Advisory and Copies: This document is available on the World Wide Web sites of the Ameri- Coordinating Committee in October 2008. can College of Cardiology (www.acc.org) and American Heart Association (my. The American College of Cardiology Foundation requests that this document americanheart.org). For copies of this document, please contact Elsevier Inc. Reprint be cited as follows: Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis Department, fax (212) 633-3820, e-mail [email protected]. GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Permissions: Multiple copies, modification, alteration, enhancement, and/or dis- Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 focused update tribution of this document are not permitted without the express permission of the incorporated into the ACC/AHA 2005 guidelines for the diagnosis and manage- American College of Cardiology Foundation. Please contact Elsevier’s permission ment of heart failure in adults: a report of the American College of Cardiology department at [email protected]. Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2009;53:e1–90. Downloaded from content.onlinejacc.org by on April 20, 2009 e2 Hunt et al. JACC Vol. 53, No. 15, 2009 2009 ACCF/AHA Heart Failure Guidelines April 14, 2009:e1–90 Task Sidney C. Smith, JR, MD, FACC, FAHA, Chair Bruce W. Lytle, MD, FACC, FAHA‡‡ Force Alice K. Jacobs, MD, FACC, FAHA, Vice-Chair Members Rick A. Nishimura, MD, FACC, FAHA Richard L. Page, MD, FACC, FAHA Christopher E. Buller, MD, FACC Lynn G. Tarkington, RN Mark A. Creager, MD, FACC, FAHA Clyde W. Yancy, MD, FACC, FAHA Steven M. Ettinger, MD, FACC Harlan M. Krumholz, MD, FACC, FAHA ‡‡Former Task Force member during the writing effort Frederick G. Kushner, MD, FACC, FAHA 4.1.1.2. TREATMENT OF DIABETES ..........................e18 TABLE OF CONTENTS 4.1.1.3. MANAGEMENT OF THE METABOLIC SYNDROME .........e18 4.1.1.4. MANAGEMENT OF ATHEROSCLEROTIC DISEASE .........e18 4.1.1.5. CONTROL OF CONDITIONS THAT MAY CAUSE Preamble (UPDATED).........................................e3 CARDIAC INJURY .................................e18 4.1.1.6. OTHER MEASURES................................e19 1. Introduction (UPDATED).................................. e5 4.1.2. Early Detection of Structural Abnormalities ......e19 4.2. Patients With Cardiac Structural Abnormalities 1.1. Evidence Review (UPDATED) ........................e5 or Remodeling Who Have Not Developed 1.2. Organization of Committee and Heart Failure Symptoms (Stage B) ................e19 Relationships With Industry (UPDATED) ...........e6 4.2.1. Prevention of Cardiovascular Events..............e20 4.2.1.1. PATIENTS WITH AN ACUTE MYOCARDIAL 1.3. Review and Approval (NEW) ........................e6 INFARCTION .....................................e20 1.4. Stages of Heart Failure (UPDATED) ................ e6 4.2.1.2. PATIENTS WITH A HISTORY OF MI BUT NORMAL LEFT 2. Characterization of Heart Failure as a VENTRICULAR EJECTION FRACTION ...................e20 4.2.1.3. PATIENTS WITH HYPERTENSION AND LEFT VENTRICULAR Clinical Syndrome.........................................e7 HYPERTROPHY...................................e20 4.2.1.4. PATIENTS WITH CHRONIC REDUCTION OF LEFT VENTRICULAR 2.1. Definition of Heart Failure...........................e7 EJECTION FRACTION BUT NO SYMPTOMS ..............e20 2.2. Heart Failure as a Symptomatic Disorder .........e7 4.2.1.5. PATIENTS WITH SEVERE VALVULAR DISEASE BUT NO 2.3. Heart Failure as a Progressive Disorder ...........e8 SYMPTOMS .....................................e20 4.2.2. Early Detection of Heart Failure .................e21 3. Initial and Serial Clinical Assessment of 4.3. Patients With Current or Prior Symptoms Patients Presenting With Heart Failure of HF (Stage C) ......................................e21 (UPDATED) .................................................e8 4.3.1. Patients With Reduced Left Ventricular Ejection Fraction (UPDATED) ..................e21 4.3.1.1. GENERAL MEASURES (UPDATED) 3.1. Initial Evaluation of Patients ......................e10 ....................e22 4.3.1.2. DRUGS RECOMMENDED FOR ROUTINE USE 3.1.1. Identification of Patients (UPDATED) ..........e10 ............e24 3.1.2. Identification of a Structural and Functional 4.3.1.2.1. DIURETICS .................................e24 Abnormality (UPDATED).......................e11 4.3.1.2.2. INHIBITORS OF THE RENIN-ANGIOTENSIN- 3.1.3. Evaluation of the Cause of Heart Failure .........e11 ALDOSTERONE SYSTEM .......................e25 3.1.3.1. HISTORY AND PHYSICAL EXAMINATION ...............e11 4.3.1.2.2.1. Angiotensin Converting Enzyme 3.1.3.2. LABORATORY TESTING (UPDATED) ...................e12 Inhibitors in the Management of 3.1.3.3. EVALUATION OF THE POSSIBILITY OF CORONARY Heart Failure ........................e26 ARTERY DISEASE.................................e13 4.3.1.2.2.2. Angiotensin Receptor Blockers........e28 3.1.3.4. EVALUATION OF THE POSSIBILITY OF MYOCARDIAL 4.3.1.2.2.3. Aldosterone Antagonists..............e29 DISEASE ........................................e13 4.3.1.2.3. BETA-ADRENERGIC RECEPTOR BLOCKERS ........e31 4.3.1.2.4. DIGITALIS ..................................e33 3.2. Ongoing Evaluation of Patients ...................e14 4.3.1.2.5. VENTRICULAR ARRHYTHMIAS AND PREVENTION 3.2.1. Assessment of Functional Capacity ...............e14 OF SUDDEN DEATH (UPDATED) .................e35 3.2.2. Assessment of Volume Status ....................e14 4.3.1.3. INTERVENTIONS TO BE CONSIDERED FOR USE IN 3.2.3. Laboratory Assessment (UPDATED) ............e15 SELECTED PATIENTS .............................. 3.2.4. Assessment of Prognosis (UPDATED) ..........e16 e37 4.3.1.3.1. ISOSORBIDE DINITRATE .......................e37 4. Therapy ....................................................e16 4.3.1.3.2. HYDRALAZINE...............................e37 4.3.1.3.3. HYDRALAZINE AND ISOSORBIDE DINITRATE 4.1. Patients at High Risk for Developing Heart (UPDATED) .................................e37 4.3.1.3.4. CARDIAC RESYNCHRONIZATION THERAPY Failure (Stage A) ....................................e16 (UPDATED) 4.1.1. Control of Risk...................................e17
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