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Click to edit Master title style,Click to edit Master text styles,Second level,Third level,J,essup et al (2009),Circulation, 2009, American Heart Association.,All rights reserved.,#,1,2009 Focused Update:,ACC/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults,2009 WRITING GROUP TO REVIEW NEW EVIDENCE AND UPDATE THE 2005 GUIDELINE FOR THE MANAGEMENT OF PATIENTS WITH CHRONIC HEART FAILURE WRITING ON BEHALF OF THE 2005 HEART FAILURE WRITING COMMITTEE Mariell Jessup, MD, FACC, FAHA, Chair; William T. Abraham, MD, FACC, FAHA; Donald E. Casey, MD, MPH, MBA; Arthur M. Feldman, MD, PhD, FACC, FAHA; Gary S. Francis, MD, FACC, FAHA; Theodore G. Ganiats, MD; Marvin A. Konstam, MD, FACC; Donna M. Mancini, MD; Peter S. Rahko, MD, FACC, FAHA; Marc A. Silver, MD, FACC, FAHA; Lynne Warner Stevenson, MD, FACC, FAHA; Clyde W. Yancy, MD, FACC, FAHA,12009 Focused Update:ACC/AHA,2,2,3,Stages in the Development of Heart Failure/Recommended Therapy by Stage. ACEI indicates angiotensin-converting enzyme,Inhibitors; ARB, angiotensin II receptor blocker: EF, ejection fraction; FHx CM, family history of cardiomyopathy, HF, heart,Failure; LVH, left ventricular hypertrophy; and MI, myocardial infarction.,3Stages in the Development of,4,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class I,A thorough history and physical examination should be obtained/performed in patients presenting with HF to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression,of HF.,(Level of Evidence: C),1. A thorough history and,physical examination,should be obtained/performed,in patients presenting with HF,to identify cardiac and,noncardiac disorders or,behaviors that might cause or,accelerate the development or,progression of HF.,(Level of,Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,4Updates to Initial and Serial,5,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class I,A careful history of current and past use of alcohol, illicit,drugs, current or past standard or “alternative therapies,” and chemotherapy drugs should be obtained from patients,presenting with HF.,(Level of Evidence: C),2. A careful history of,current and past use of,alcohol, illicit drugs, current,or past standard or,“alternative therapies,” and,chemotherapy drugs should,be obtained from patients,presenting with HF.,(Level of,Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,5Updates to Initial and Serial,6,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class I,In patients presenting with HF, initial assessment should be made of the patients ability to perform routine and desired,activities of daily living.,(Level of Evidence: C),3. In patients presenting with,HF, initial assessment,should be made of the,patients ability to perform,routine and desired activities,of daily living.,(Level,of Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,6Updates to Initial and Serial,7,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class I,Initial examination of patients presenting with HF should include assessment of the patients volume status, orthostatic blood pressure changes, measurement of weight,and height, and calculation of body mass index.,(Level of Evidence: C,4. Initial examination of,patients presenting with HF,should include assessment,of the patients volume,status, orthostatic blood,pressure changes,measurement of weight and,height, and calculation,of body mass index.,(Level,of Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,7Updates to Initial and Serial,8,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class I,Initial laboratory evaluation of patients presenting with HF should include complete blood count, urinalysis, serum electrolytes (including calcium and magnesium), blood urea nitrogen, serum creatinine, fasting blood glucose (glycohemoglobin), lipid profile, liver function tests, and thyroid-stimulating hormone.,(Level of Evidence: C),5. Initial laboratory evaluation of,patients presenting with HF should,include complete blood count,urinalysis, serum electrolytes,(including calcium and,magnesium), blood urea nitrogen,serum creatinine, fasting blood,glucose (glycohemoglobin),lipid profile, liver function,tests, and thyroid-stimulating,hormone.,(Level of,Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,8Updates to Initial and Serial,9,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class I,Twelve-lead electro-cardiogram and chest radiograph (posterior to,anterior PA and lateral) should be performed initially in all patients presenting with HF.,(Level of Evidence: C),6. Twelve-lead electro-,cardiogram and chest,radiograph (PA and lateral),should be performed,initially in all patients,presenting with HF.,(Level of,Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,9Updates to Initial and Serial,10,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class I,Two-dimensional echo-cardiography with Doppler should be performed during initial evaluation of patients presenting with HF to assess left ventricular ejection fraction (LVEF), LV size, wall thickness, and valve function. Radionuclide,ventriculography can be performed to assess LVEF and volumes.,(Level of Evidence: C),7. Two-dimensional echo-,cardiography with Doppler should be,performed during initial evaluation of,patients presenting with HF to,assess LVEF, left ventricular size,wall thickness, and valve function.,Radionuclide ventriculography can,be performed to assess LVEF and,volumes.,(Level of Evidence: C,2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,10Updates to Initial and Seria,11,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class I,Coronary arteriography should be performed in patients presenting with HF who have angina or significant ischemia,unless the patient is not eligible for revascularization of any kind.,(Level of Evidence: B),8. Coronary arteriography should be,performed in patients presenting with,HF who have angina or significant,ischemia unless the patient is not,eligible for revascularization of any,kind.,(Level of Evidence: B,2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,11Updates to Initial and Seria,12,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class IIa,Coronary arteriography should be performed in patients presenting with HF who have angina or significant ischemia unless the patient is not eligible for revascularization of any kind. (,Level o Evidence: B),1. Coronary arteriography should be,performed in patients presenting with,HF who have angina or significant,ischemia unless the patient is not,eligible for revascularization of any,kind.,(Level of Evidence: B,2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,12Updates to Initial and Seria,13,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class IIa,Coronary arteriography is reasonable for patients presenting with HF who have chest pain that may or may not be of cardiac origin who have not had evaluation of their coronary anatomy and who have no contraindications to coronary,revascularization.,(Level of Evidence: C),2. Coronary arteriography is,reasonable for patients,presenting with HF who,have chest pain that may,or may not be of cardiac,origin who have not had,evaluation of their coronary,anatomy and who have no,contraindications to coronary,revascularization.,(Level of,Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,13Updates to Initial and Seria,14,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class IIa,Noninvasive imaging to detect myocardial ischemia and viability is reasonable in patients presenting with HF who have known coronary artery disease and no angina unless the patient is not eligible for revascularization of any kind.,(Level of Evidence: B),3. Noninvasive imaging to,detect myocardial ischemia,and viability is reasonable in,patients presenting with,HF who have known,coronary artery disease and,No angina unless the patient,is not eligible for,revascularization of any,kind.,(Level of Evidence: B),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,14Updates to Initial and Seria,15,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class IIa,Maximal exercise testing with or without measurement of respiratory gas exchange and/or blood oxygen saturation is reasonable in patients presenting with HF to help determine whether HF is the cause of exercise limitation when the,contribution of HF is uncertain.,(Level of Evidence: C),4. Maximal exercise testing with or,without measurement of respiratory,gas exchange and/or blood oxygen,saturation is reasonable in patients,presenting with HF to help determine,whether HF is the cause of exercise,limitation when the contribution of HF,is uncertain.,(Level of Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,15Updates to Initial and Seria,16,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class IIa,Maximal exercise testing with measurement of respiratory gas exchange is reasonable to identify high-risk patients presenting with HF who are candidates for cardiac transplantation or other advanced treatments.,(Level of Evidence: B),5. Maximal exercise testing,with measurement of,respiratory gas exchange is,reasonable to identify,high-risk patients presenting,with HF who are candidates,for cardiac transplantation or,Other advanced,treatments.,(Level of,Evidence: B),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,16Updates to Initial and Seria,17,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class IIa,Screening for hemo-chromatosis, sleep-disturbed breathing, or human immunodeficiency virus is reasonable in selected,patients who present with HF.,(Level of Evidence: C),6. Screening for hemo-,chromatosis, sleep-disturbed,breathing, or human,immunodeficiency virus is,reasonable in selected,patients who present with,HF.,(Level of Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,17Updates to Initial and Seria,18,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class IIa,Diagnostic tests for rheumatologic diseases, amyloidosis, or,pheochromocytoma are reasonable in patients presenting with HF in whom there is a clinical suspicion of these diseases.,(Level of Evidence: C),7. Diagnostic tests for,rheumatologic diseases,amyloidosis, or,pheochromocytoma are,Reasonable in patients,presenting with HF in whom,there is a clinical suspicion,of these diseases.,(Level of,Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,18Updates to Initial and Seria,19,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class IIa,Endomyocardial biopsy can be useful in patients presenting with HF when a specific diagnosis is suspected that would,influence therapy.,(Level of Evidence: C),8. Endomyocardial biopsy,can be useful in patients,presenting with HF when a,specific diagnosis is,suspected that would,influence therapy.,(Level,of Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,19Updates to Initial and Seria,20,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class IIa,Measurement of BNP can be useful in the evaluation of,patients presenting in the urgent care setting in whom the clinical diagnosis of HF is uncertain.,(Level of Evidence: A),9. Measurement of natriuretic,peptides (BNP and NTproBNP) can,be useful in the evaluation of,patients presenting in the urgent,care setting in whom the clinical,diagnosis of HF is uncertain.,Measurement of natriuretic,peptides (BNP and NT-proBNP),can be useful in risk stratification.,(Level of Evidence: A),Modified recommendation,(added a caveat on,natriuretic peptides and their,role as part of total,evaluation, in both diastolic,and systolic dysfunction).,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,20Updates to Initial and Seria,21,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class IIb,Noninvasive imaging may be considered to define the,likelihood of coronary artery disease in patients with HF and LV dysfunction.,(Level of Evidence: C),1. Noninvasive imaging may,be considered to define,the likelihood of coronary,artery disease in patients,with HF and LV dysfunction.,(Level of Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,21Updates to Initial and Seria,22,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class IIb,Holter monitoring might be considered in patients presenting with HF who have a history of myocardial infarction (MI) and are being considered for electrophysiologic study to,document ventricular tachycardia (VT) inducibility.,(Level of Evidence: C),2. Holter monitoring might be,considered in patients,presenting with HF who,have a history of MI and,are being considered for,electrophysiologic study,to document VT inducibility.,(Level of Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,22Updates to Initial and Seria,23,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class III,Endomyocardial biopsy should not be performed in the routine evaluation of patients with HF.,(Level of Evidence: C),1. Endomyocardial biopsy,should not be performed,in the routine evaluation of,patients with HF.,(Level of Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,23Updates to Initial and Seria,24,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class III,Routine use of signal-averaged electro-cardiography is not,recommended for the evaluation of patients presenting with HF.,(Level of Evidence: C),2. Routine use of signal-,averaged electrocardiography,is not recommended for the,evaluation of patients,presenting with HF.,(Level,of Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,24Updates to Initial and Seria,25,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class III,Routine measurement of circulating levels of neurohormones,(e.g., norepinephrine or endothelin) is not recommended for,patients presenting with HF.,(Level of Evidence: C),3. Routine measurement of,circulating levels of,neurohormones (e.g.,norepinephrine or,endothelin) is not,recommended for patients,presenting with HF.,(Level of,Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for the Initial Clinical Assessment of Patients with Heart Failure,25Updates to Initial and Seria,26,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class I,Assessment should be made at each visit of the ability of a,patient with HF to perform routine and desired activities of daily living.,(Level of Evidence: C),1. Assessment should be,made at each visit of the,ability of a patient with HF to,perform routine and desired,activities of daily living.,(Level,of Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for Serial Clinical Assessment of Patients Present with Heart Failure,26Updates to Initial and Seria,27,Updates to Initial and Serial Clinical Assessments of Patients Presenting with Heart Failure,2005 Guideline Recommendations,2009 Focused Update Recommendations,Comments,Class I,Assessment should be made at each visit of the volume,status and weight of a patient with HF.,(Level of Evidence:,C),2. Assessment should be,made at each visit of the,volume status and weight of a,patient with HF.,(Level of,Evidence: C),2005 recommendation remains current in the 2009 update.,Recommendations for Serial Clinical Assessment of Patients Present with Heart Failure,27Updates to Initial
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