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©2013 UpToDate ® Print Email ACC/AHA guideline summary: Management of adults with current or prior symptoms of heart failure (HF) and a reduced left ventricular ejection fraction (LVEF) (HF stage C) Class I - There is evidence and/or general agreement that the following approaches are effective in the management of patients with current or prior symptoms of HF and a reduced LVEF • Diuretics and salt restriction for fluid retention. • Angiotensin converting enzyme (ACE) inhibitors in all patients, unless contraindicated. • Beta blockers in all stable patients, unless contraindicated. One of the three beta blockers proven to reduce mortality should be used (bisoprolol, carvedilol, and sustained release metoprolol succinate). • Angiotensin II receptor blockers (ARBs) in patients who do not tolerate ACE inhibitors. • Drugs that can adversely affect the patient's clinical status should be avoided or withdrawn, if possible. These include nonsteroidal antiinflammatory drugs, most antiarrhythmic drugs, and most calcium channel blockers. • Exercise training as an adjunctive approach to improve clinical status in ambulatory patients. • An implantable cardioverter-defibrillator (ICD) for secondary prevention to prolong survival in patients with a history of cardiac arrest, ventricular fibrillation, or hemodynamically destabilizing ventricular tachycardia. • An ICD for primary prevention to reduce total mortality by preventing sudden cardiac death (SCD) in patients with non-ischemic or ischemic heart disease who meet the following criteria: at least 40 days post-myocardial infarction, an LVEF ≤35 percent, New York Heart Association functional class II or III symptoms despite optimal chronic medical therapy, and a reasonable expectation of survival with a good functional status for more than one year. • Cardiac resynchronization therapy (CRT), with or without an ICD, unless contraindicated, in patients who meet the following criteria: cardiac dyssynchrony as defined by a QRS duration >120 msec, LVEF ≤35 percent, sinus rhythm, and New York Heart Association functional class III or ambulatory class IV symptoms despite optimal medical therapy.

• Cardiac resynchronization therapy (CRT), with or without an ICD, unless contraindicated, in patients who meet the following criteria: cardiac dyssynchrony as defined by a QRS duration >120 msec, LVEF ≤35 percent, sinus rhythm, and New York Heart Association functional class III or ambulatory class IV symptoms despite optimal medical therapy. • Addition of an aldosterone antagonist is recommended in selected patients with moderately severe to severe symptoms of HF and reduced LVEF who can be carefully monitored for preserved renal function and normal potassium concentration. Creatinine should be ≤2.5 mg per dL in men or ≤2.0 mg per dL in women and potassium should be <5.0 mEq per liter. Under circumstances in which monitoring for hyperkalemia and renal dysfunction is not anticipated to be feasible, the risks may outweigh the benefits of aldosterone antagonists. • The combination of hydralazine and nitrates is recommended to improve outcomes for patients self-described as African-Americans, with moderate-severe symptoms on optimal therapy with ACE inhibitors, beta blockers, and diuretics. Class IIa - The weight of evidence and/or opinion is in favor of the following approaches being effective in the management of patients with current or prior symptoms of HF and a reduced LVEF • It is reasonable to treat patients with atrial fibrillation and HF with a strategy to maintain sinus rhythm or with a strategy to control ventricular rate alone. • Maximal exercise testing with or without measurement of respiratory gas exchange is reasonable to facilitate prescription of an appropriate exercise program for patients presenting with HF. • ARBs as an alternative to ACE inhibitors as first-line therapy in patients with mild to moderate HF, particularly those already taking an ARB for other indications. • Digitalis in patients with current or prior symptoms of HF to reduce hospitalization for HF. • The addition of the combination of hydralazine and a nitrate in patients with persistent symptoms who are already taking an ACE inhibitor and beta blocker. • CRT with or without an ICD is reasonable in patients with an LVEF of ≤35 percent, a QRS ≥0.12 seconds, and atrial fibrillation who have New York Heart Association functional class III or ambulatory class IV symptoms symptoms despite optimal chronic medical therapy.

• The addition of the combination of hydralazine and a nitrate in patients with persistent symptoms who are already taking an ACE inhibitor and beta blocker. • CRT with or without an ICD is reasonable in patients with an LVEF of ≤35 percent, a QRS ≥0.12 seconds, and atrial fibrillation who have New York Heart Association functional class III or ambulatory class IV symptoms symptoms despite optimal chronic medical therapy. • CRT is reasonable in patients with an LVEF of ≤35 percent who have New York Heart Association functional class III or ambulatory class IV symptoms despite optimal medical therapy and who have frequent dependence of ventricular pacing. Class IIb - The weight of evidence and/or opinion is less well established for the following approaches in the management of patients with current or prior symptoms of HF and a reduced LVEF • The combination of hydralazine and a nitrate in patients who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency. • Addition of an ARB in patients with persistent symptoms who are already being treated with an ACE inhibitor, beta blocker, and diuretics. Class III - There is evidence and/or general agreement that the following approaches are not effective and may be harmful in the management of patients with current or prior symptoms of HF and a reduced LVEF • Routine use of triple therapy with an ACE inhibitor, an ARB, and an aldosterone receptor antagonist is not recommended. • Routine administration of calcium channel blockers is not indicated. • Long-term infusion of a positive inotropic drug may be harmful and is not recommended, except as palliation for end-stage disease that cannot be stabilized with standard medical therapy. • Nutritional supplements are not indicated. • Hormonal therapies may be harmful and are not recommended unless given to replete hormone deficiencies. Data from Hunt SA, Abraham WT, Chin MH, et al. 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. Circulation 2009; 119:e391. ACC/AHA/ESC guideline summary: Management of patients with heart failure (HF) and preserved systolic function

Data from Hunt SA, Abraham WT, Chin MH, et al. 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. Circulation 2009; 119:e391. ACC/AHA/ESC guideline summary: Management of patients with heart failure (HF) and preserved systolic function Class I - There is evidence and/or general agreement that the following approaches are effective in the management of HF and preserved left ventricular systolic function • Control of hypertension, both systolic and diastolic, according to current guidelines. • Control of ventricular rate in atrial fibrillation. • Control of pulmonary congestion and peripheral edema with diuretics. Class IIa - The weight of evidence or opinion is in favor of the usefulness of the following approach in the management of HF and preserved left ventricular systolic function • Coronary revascularization for symptomatic or asymptomatic myocardial ischemia that is thought to have an adverse effect of cardiac function. Class IIb - The weight of evidence or opinion is less well established for the usefulness of the following approaches in the management of HF and preserved left ventricular systolic function • Restoration of sinus rhythm to improve diagnosis in patients with atrial fibrillation. • Among patients controlled hypertension, use of beta blockers, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, and calcium channel blockers in an attempt to reduce symptoms of HF. • Digitalis to reduce symptoms of HF. Data from: Hunt SA, Abraham WT, Chin MH, et al. 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. Circulation 2005; 112:e154.

• The addition of the combination of hydralazine and a nitrate in patients with persistent symptoms who are already taking an ACE inhibitor and beta blocker. • CRT with or without an ICD is reasonable in patients with an LVEF of ≤35 percent, a QRS ≥0.12 seconds, and atrial fibrillation who have New York Heart Association functional class III or ambulatory class IV symptoms symptoms despite optimal chronic medical therapy. • CRT is reasonable in patients with an LVEF of ≤35 percent who have New York Heart Association functional class III or ambulatory class IV symptoms despite optimal medical therapy and who have frequent dependence of ventricular pacing. Class IIb - The weight of evidence and/or opinion is less well established for the following approaches in the management of patients with current or prior symptoms of HF and a reduced LVEF • The combination of hydralazine and a nitrate in patients who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency. • Addition of an ARB in patients with persistent symptoms who are already being treated with an ACE inhibitor, beta blocker, and diuretics. Class III - There is evidence and/or general agreement that the following approaches are not effective and may be harmful in the management of patients with current or prior symptoms of HF and a reduced LVEF • Routine use of triple therapy with an ACE inhibitor, an ARB, and an aldosterone receptor antagonist is not recommended. • Routine administration of calcium channel blockers is not indicated. • Long-term infusion of a positive inotropic drug may be harmful and is not recommended, except as palliation for end-stage disease that cannot be stabilized with standard medical therapy. • Nutritional supplements are not indicated. • Hormonal therapies may be harmful and are not recommended unless given to replete hormone deficiencies. Data from Hunt SA, Abraham WT, Chin MH, et al. 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. Circulation 2009; 119:e391. ACC/AHA guideline summary: Management of concomitant diseases in patients with heart failure (HF)

Data from Hunt SA, Abraham WT, Chin MH, et al. 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. Circulation 2009; 119:e391. ACC/AHA guideline summary: Management of concomitant diseases in patients with heart failure (HF) Class I - There is evidence and/or general agreement that the following approaches are effective for the management of concomitant diseases in patients with HF. • All recommendations for HF therapy should apply to patients with concomitant disorders unless there are specific exceptions. • Treatment of concomitant diseases: 1. Control of systolic and diastolic hypertension according to current guidelines. 2. Control of diabetes mellitus according to current guidelines. 3. Nitrates and beta blockers for the treatment of angina. 4. Coronary revascularization for angina according to current guidelines. 5. Anticoagulation for paroxysmal or persistent atrial fibrillation or a previous thromboembolic event. 6. Control of the ventricular response in patients with atrial fibrillation with a beta blocker (or amiodarone if the beta-blocker is contraindicated or not tolerated). 7. Treatment of coronary artery disease according to current guidelines. 8. Antiplatelet agents for prevention of MI and death in patients with coronary artery disease. Class IIa - The weight of evidence or opinion is in favor of the usefulness of the following approaches for the management of concomitant diseases in patients with HF • Control the ventricular response in patients with atrial fibrillation with digitalis. • Amiodarone to decrease recurrence of atrial arrhythmias and recurrence of implantable cardioverter-defibrillator discharge for ventricular arrhythmias. Class IIb - The weight of evidence or opinion is less well established for the usefulness of the following approaches for the management of concomitant diseases in patients with HF • Restoration and maintenance of sinus rhythm in patients with atrial fibrillation. • Anticoagulation in the absence of atrial fibrillation or a previous thromboembolic events. • Enhancing erythropoiesis in patients with anemia.

Class IIb - The weight of evidence or opinion is less well established for the usefulness of the following approaches for the management of concomitant diseases in patients with HF • Restoration and maintenance of sinus rhythm in patients with atrial fibrillation. • Anticoagulation in the absence of atrial fibrillation or a previous thromboembolic events. • Enhancing erythropoiesis in patients with anemia. Class III - There is evidence and/or general agreement that the following approaches are not useful or may be harmful for the management of concomitant diseases in patients with HF • Class I or III antiarrhythmic drugs to prevent ventricular arrhythmias. • Antiarrhythmic drugs as primary treatment of asymptomatic ventricular arrhythmias or to improve survival. Data from Hunt SA, Abraham WT, Chin MH, et al. 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. Circulation 2009; 119:e391.

• The addition of the combination of hydralazine and a nitrate in patients with persistent symptoms who are already taking an ACE inhibitor and beta blocker. • CRT with or without an ICD is reasonable in patients with an LVEF of ≤35 percent, a QRS ≥0.12 seconds, and atrial fibrillation who have New York Heart Association functional class III or ambulatory class IV symptoms symptoms despite optimal chronic medical therapy. • CRT is reasonable in patients with an LVEF of ≤35 percent who have New York Heart Association functional class III or ambulatory class IV symptoms despite optimal medical therapy and who have frequent dependence of ventricular pacing. Class IIb - The weight of evidence and/or opinion is less well established for the following approaches in the management of patients with current or prior symptoms of HF and a reduced LVEF • The combination of hydralazine and a nitrate in patients who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency. • Addition of an ARB in patients with persistent symptoms who are already being treated with an ACE inhibitor, beta blocker, and diuretics. Class III - There is evidence and/or general agreement that the following approaches are not effective and may be harmful in the management of patients with current or prior symptoms of HF and a reduced LVEF • Routine use of triple therapy with an ACE inhibitor, an ARB, and an aldosterone receptor antagonist is not recommended. • Routine administration of calcium channel blockers is not indicated. • Long-term infusion of a positive inotropic drug may be harmful and is not recommended, except as palliation for end-stage disease that cannot be stabilized with standard medical therapy. • Nutritional supplements are not indicated. • Hormonal therapies may be harmful and are not recommended unless given to replete hormone deficiencies. Data from Hunt SA, Abraham WT, Chin MH, et al. 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. Circulation 2009; 119:e391.