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ACC/AHA 2005 Guideline Update for the Diagnosis and Management Of © 2005 by the American College of Cardiology Foundation and the American Heart Association, Inc. ACC/AHA PRACTICE GUIDELINES—FULL TEXT ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure) Developed in Collaboration With the American College of Chest Physicians and the International Society for Heart and Lung Transplantation Endorsed by the Heart Rhythm Society WRITING COMMITTEE MEMBERS Sharon Ann Hunt, MD, FACC, FAHA, Chair William T. Abraham, MD, FACC, FAHA Donna M. Mancini, MD Marshall H. Chin, MD, MPH, FACP Keith Michl, MD, FACP Arthur M. Feldman, MD, PhD, FACC, FAHA John A. Oates, MD, FAHA Gary S. Francis, MD, FACC, FAHA Peter S. Rahko, MD, FACC, FAHA Theodore G. Ganiats, MD Marc A. Silver, MD, FACC, FAHA Mariell Jessup, MD, FACC, FAHA Lynne Warner Stevenson, MD, FACC, FAHA Marvin A. Konstam, MD, FACC Clyde W. Yancy, MD, FACC, FAHA TASK FORCE MEMBERS Elliott M. Antman, MD, FACC, FAHA, Chair Sidney C. Smith, Jr., MD, FACC, FAHA, Vice Chair Cynthia D. Adams, MSN, APRN-BC, FAHA Sharon Ann Hunt, MD, FACC, FAHA Jeffrey L. Anderson, MD, FACC, FAHA Alice K. Jacobs, MD, FACC, FAHA David P. Faxon, MD, FACC, FAHA* Rick Nishimura, MD, FACC, FAHA Valentin Fuster, MD, PhD, FACC, FAHA, FESC* Joseph P. Ornato, MD, FACC, FAHA Jonathan L. Halperin, MD, FACC, FAHA Richard L. Page, MD, FACC, FAHA Loren F. Hiratzka, MD, FACC, FAHA* Barbara Riegel, DNSc, RN *Former Task Force Member Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org) and the American Heart This document was approved by the American College of Cardiology Association (www.my.americanheart.org). Single copies of this document are Foundation Board of Trustees in August 2005 and by the American Heart available by calling 1-800-253-4636 or writing the American College of Association Science Advisory and Coordinating Committee in August 2005. Cardiology Foundation, Resource Center, at 9111 Old Georgetown Road, Bethesda, MD 20814-1699. Ask for reprint number 71-0327. To obtain a reprint When citing this document, the American College of Cardiology Foundation of the Summary Article published in the September 20, 2005 issues of the Journal of the American College of Cardiology and Circulation, ask for reprint requests that the following citation format be used: Hunt SA, Abraham WT, number 71-0328. To purchase bulk reprints (specify version and reprint num- Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, ber): Up to 999 copies, call 1-800-611-6083 US only) or fax 413-665-2671; Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy 1000 or more copies, call 214-706-1789, fax 214-691-6342, or e-mail pub- CW. ACC/AHA 2005 guideline update for the diagnosis and management of [email protected]. chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Permissions: Multiple copies, modification, alteration, enhancement, and/or (Writing Committee to Update the 2001 Guidelines for the Evaluation and distribution of this document are not permitted without the express permission Management of Heart Failure). American College of Cardiology Web Site. of the American College of Cardiology Foundation. Please direct requests to Available at: http://www.acc.org/clinical/guidelines/failure//index.pdf. [email protected]. Hunt et al. 2005 ACC - www.acc.org 2 ACC/AHA Practice Guidelines AHA - www.americanheart.org TABLE OF CONTENTS 4.3.1.2.2.1. Angiotensin Converting Enzyme Preamble.................................................................................... 3 Inhibitors.............24 1. Introduction............................................................................3 4.3.1.2.2.2. Angiotensin 2. Characterization of HF as a Clinical Syndrome....................7 Receptor 2.1. Definition of HF............................................................. 7 Blockers.............. 27 2.2. HF as a Symptomatic Disorder...................................... 7 4.3.1.2.2.3. Aldosterone 2.3. HF as a Progressive Disorder......................................... 7 Antagonists......... 29 3. Initial and Serial Clinical Assessment of Patients 4.3.1.2.3. Beta-Adrenergic Receptor Presenting With HF................................................................8 Blockers.................................30 3.1. Initial Evaluation of Patients........................................10 4.3.1.2.4. Digitalis................................. 33 3.1.1. Identification of Patients.....................................10 4.3.1.2.5. Ventricular Arrhythmias and 3.1.2. Identification of a Structural and Functional Prevention of Sudden Abnormality........................................................ 10 Death......................................34 3.1.3. Evaluation of the Cause of HF............................11 4.3.1.3. Interventions to Be Considered for Use 3.1.3.1. History and Physical Examination........11 in Selected Patients............................... 37 3.1.3.2. Laboratory Testing................................ 11 4.3.1.3.1. Isosorbide Dinitrate...............37 3.1.3.3. Evaluation of the Possibility of 4.3.1.3.2. Hydralazine........................... 37 Coronary Artery Disease.......................12 4.3.1.3.3. Hydralazine and Isosorbide 3.1.3.4. Evaluation of the Possibility of Dinitrate.................................37 Myocardial Disease...............................13 4.3.1.3.4. Cardiac Resynchronization 3.2. Ongoing Evaluation of Patients................................... 13 Therapy.................................. 37 3.2.1. Assessment of Functional Capacity.................... 13 4.3.1.3.5. Exercise Training.................. 38 3.2.2. Assessment of Volume Status............................. 14 4.3.1.4. Drugs and Interventions Under Active 3.2.3. Laboratory Assessment.......................................14 Investigation.......................................... 39 3.2.4. Assessment of Prognosis.................................... 15 4.3.1.4.1. Techniques for Respiratory Support.................................. 39 4. Therapy................................................................................ 15 4.3.1.4.2. External Counterpulsation.....39 4.1. Patients at High Risk for Developing HF (Stage A)....15 4.3.1.4.3. Vasopressin Receptor 4.1.1. Control of Risk................................................... 16 Antagonists............................39 4.1.1.1. Treatment of Hypertension....................16 4.3.1.4.4. Implantable Hemodynamic 4.1.1.2. Treatment of Diabetes........................... 17 4.1.1.3. Management of the Metabolic Monitors................................ 39 Syndrome...............................................17 4.3.1.4.5. Cardiac Support Devices.......39 4.1.1.4. Management of Atherosclerotic 4.3.1.4.6. Surgical Approaches Under Disease...................................................17 Investigation.......................... 40 4.1.1.5. Control of Conditions That May Cause 4.3.1.4.7. Nesiritide............................... 40 Cardiac Injury........................................18 4.3.1.5. Drugs and Interventions of Unproved 4.1.1.6. Other Measures..................................... 18 Value and Not Recommended...............40 4.1.2. Early Detection of Structural Abnormalities...... 18 4.3.1.5.1. Nutritional Supplements and 4.2. Patients With Cardiac Structural Abnormalities or Hormonal Therapies.............. 40 Remodeling Who Have Not Developed HF 4.3.1.5.2. Intermittent Intravenous Symptoms (Stage B).......................................... 18 Positive Inotropic Therapy.... 40 4.2.1. Prevention of Cardiovascular Events................. 19 4.3.2. Patients With HF and Normal LVEF.................. 41 4.2.1.1. Patients With an Acute MI....................19 4.3.2.1. Identification of Patients....................... 41 4.2.1.2. Patients With a History of MI but 4.3.2.2. Diagnosis...............................................42 Normal LVEF........................................ 19 4.3.2.3. Principles of Treatment......................... 43 4.2.1.3. Patients With Hypertension and LVH...19 4.4. Patients With Refractory End-Stage HF (Stage D)......43 4.2.1.4. Patients With Chronic Reduction of 4.4.1. Management of Fluid Status...............................44 LVEF but No Symptoms.......................19 4.4.2. Utilization of Neurohormonal Inhibitors............44 4.2.1.5. Patients With Severe Valvular Disease 4.4.3. Intravenous Peripheral Vasodilators and Positive but No Symptoms..................................20 Inotropic Agents..................................................45 4.2.2. Early Detection of HF.........................................20 4.4.4. Mechanical and Surgical Strategies....................45 4.3. Patients With Current or Prior Symptoms of HF 5. Treatment of Special Populations........................................46 (Stage C).......................................................................20 5.1. Women and Men...........................................................46 4.3.1. Patients With Reduced LVEF............................. 20 5.2. Ethnic Considerations...................................................47 4.3.1.1. General Measures..................................22
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