The AHA Guidelines and Scientific Statements Handbook

Chapter 13 Heart Failure

Table 13.6 Heart Failure Guidelines across societies

ESC ACC/AHA CCS HFSA

Level Class Level Class Level Class Level Class

ACE – inhibitor A I A I A I A I
Beta-blocker A I A I A I A I
Aldosterone antagonists: moderate-severe symptoms/advanced HF B I B I B I A I
ARB
ACE – inhibitor intolerant B I A I A I A I
ACE – inhibitor treated – – B IIb A I A IIa
To reduce mortalitya B IIa – – – – – –
To reduce hospitalizationa AI ––––––
Digoxin (sinus rhythm) A IIa B IIa A I Ab IIa
Hydralazine – Isosorbide dinitrate
ACE – inhibitor / ARB intolerant B IIa C IIb B IIb C IIad
ACE – inhibitor – treatede – – B IIa A IIa Ac I

a Only ESC guideline distinguishes between outcomes.
b NYHA classes II–III (level B in NYHA class IV).
c NYHA III or IV (level B in NYHA class II).
d IIa if intolerance because of renal insuffi ciency/hyperkalemia (otherwise ARB preferred and H-ISDN given a lib recommendation).
e African-Americans.

After reference 3, with permission.

formulated hydralazine-nitrate combination. Nev-
ertheless, no trials have addressed which of these
successful interventions should be tried fi rst for an
individual patient who continues to be symptomatic
despite optimal therapy. Guideline committees must
then struggle to make reasonable interpretations of
these data as they organize their reports. Are the
outcomes of these trials valid for the current
population of patients who may be on several addi-
tional drugs? Writing committees may consider
these historical comparisons with widely divergent
opinions.
Yet another area in which guideline writing com-
mittees disagree is their willingness to apply thera-
pies to all heart failure patients which have only been
studied in a specifi c subset of patients. Some exam-
ples of such dilemmas include the use of ICDs in
patients who have never had heart failure symp-
toms, the use of spironolactone in asymptoma-
tic patients, and the use of hydralazine-nitrates
in patients other than African Americans. Achiev-
ing a consensus on these diffi cult items and
scores of other equally contentious topics is
unlikely.

Future directions

There is much to be done to improve the overall HF

guideline development process. Future initiatives

include:

1 A method to review and update the guidelines in

a timely manner.

2 A method to simplify the guidelines so that they

may be easily conveyed, and, most importantly,

implemented.

3 Inclusion of recommendations for the manage-

ment of acutely decompensated patients with HF.

4 Attempt to reconcile the differences between

other organizations’ guidelines.

References available online at http://www.Wiley.com/go/

AHAGuidelineHandbook.

During the production of this book these relevant

AHA statements and guidelines were published:

Prevention of Heart Failure, http://circ.ahajournals.

org/cgi/content/full/117/19/2544; Sleep Apnea and

Cardiovascular Disease, http://circ.ahajournals.org/

cgi/reprint/CIRCULATIONAHA.107.189420.