When it comes to treating the exacerbations of heart failure, which cause more than 1 million hospital admissions annually, there is mixed news for physicians.
The good news is that the armamentarium of therapeutic options is rapidly expanding, giving you more choices to treat these patients. The downside? Sorting through the plethora of treatments is becoming a somewhat daunting task.
That’s where new guidelines released last fall by the American College of Cardiology and the American Heart Association can help. While the two groups have released heart failure guidelines before, they break new ground with this update by recommending specific drugs and doses to treat heart failure. The new recommendations are a reaction to evidence showing that when it comes to treating heart failure, all drug therapies are not equal.
The new guidelines, which were published in the Sept. 20, 2005, issue of Circulation, also stand out from older guidance by emphasizing the long-range benefits of detecting and treating patients earlier in the disease. And for patients suffering from symptomatic heart failure, the recommendations talk about the role that devices like implantable defibrillators and cardiac resynchronization therapies can play.
Today’s Hospitalist talked to one of the guidelines’ authors, Clyde Yancy, MD, professor of medicine and medical director of heart failure/transplantation at UT Southwestern Medical Center in Dallas, for a perspective on what the recent guidelines mean for hospitalists.
What do you consider the “big news” items in this guideline update?
There are several themes that are very important, even though they don’t necessarily implicate in-hospital therapies. What’s new now is an even higher requirement, class I , for use of an ACE or a similarly high requirement for strong consideration of an ARB. It used to be that an ACE was recommended preferentially, and an ARB only in intolerance cases. But we now give a fairly high-level recommendation to using an ARB in an a priori manner if patients have another indication for an ARB, or if that is the physician’s preference.
In addition, aldosterone antagonists are treated with a much higher degree of confidence than in 2001. We have more data on the potential benefits of these drugs in heart failure, but also more respect for the data regarding the risks “hyperkalemia in particular “associated with aldosterone antagonists. Some patients are at risk for hyperkalemia even after they’ve already been established on aldosterone antagonists, so we constructed a separate table to advise practitioners on the strategies they should respect in administering these drugs.
What recommendations do the guidelines make about prescribing beta-blockers?
The other change that’s very important is that particularly for beta-blockers, we don’t acknowledge a class effect. Certainly for ACEs, we believe there is a class effect. But for beta-blockers, there has been a debate in medicine that perhaps this is an effect that can be seen with any drug that disrupts the sympathetic nervous system.
This is the first time that an ACC/AHA guideline committee specifically enumerates which drug to give for a specific guideline (heart-failure patients with low ejection fraction). The point is to use one of the three evidence-based beta-blockers “bisoprolol, carvedilol and extended-release metoprolol “because the others haven’t been found favorable in patients with heart failure.
How do the guidelines recognize factors like race in tailoring therapy?
This is yet another important theme in the guidelines requiring an increased acknowledgement and awareness of unique populations with heart failure. That includes gender, age and especially race, with the focus on African-Americans.
The latter is especially important because there is now a unique therapy “a fixed-dose combination of isosorbide dinitrate and hydralazine “that may be especially beneficial in African-Americans. That gets a IIa recommendation.
These really reflect unique treatment strategies that were not identified in the first set of guidelines in 2001.
The update addresses a wide range of drugs and options. Why do the guidelines delineate so many drugs and their recommended dosing schedules, and how should hospitalists incorporate this guidance into their treatment?
That’s primarily because so many therapies have been studied and been shown to be potentially beneficial in heart failure. A practitioner can select from several loop diuretics, eight ACE inhibitors, three beta-blockers and two ARBs.
It’s a fairly robust list, so these guidelines are a great tool for hospitalists to seek treatment options. They can realize they don’t have to feel locked into one diuretic or one ACE inhibitor, for example. That may be intimidating at first, but it should be reassuring for hospitalists that there are a number of “right answers.”
What’s interesting is that hospitalists are the focal point of what may be the most significant problem in heart failure right now. It’s not adherence to guidelines or acknowledgement of performance measures; it has to do with what are the specific ways that are effective in the management of the patient admitted with acute decompensated heart failure.
We all suspect that hospitalists are at the “front line” in the management of decompensated heart failure. That really has become a lightning rod of interest for many of us in part because so much of [that treatment] is based on clinical judgment, very little is based on clinical trial data, and none is based on guidelines.
Even though these guidelines address chronic heart failure ” guidelines for acute decompensated disease will come out soon “hospitalists can use these current guidelines to take advantage of every heart failure admission to improve the natural history of the disease by optimizing patients’ therapies.
The new guidelines replace the long-used term congestive heart failure with just heart failure. What prompted this change?
This may sound like mere wordsmithing or a nomenclature change, but it absolutely is not. In the chronic or classical context, congestive heart failure, by its very nomenclature, implies an overtly symptomatic state because someone is volume overloaded. Heart failure, however, captures the entire spectrum of the disease, from being at risk for disease (which we call stage A) to having asymptomatic left-ventricular dysfunction (stage B), to having overt heart failure, which is stage C now. Stage D indicates having persistent symptoms despite being on effective therapies.
That means that the phrase heart failure now allows us to be more integrative in our thought, while the phrase “congestive heart failure” is more confining and misses the opportunity to intervene earlier in this disease construct. Now we can consider patients who are at risk for disease “those with hypertension, diabetes, dyslipidemia who don’t have LV dysfunction or symptoms ” as a targeted at-risk population.
The point is that we can now intervene in this earlier at-risk population in a proactive way because we have compounds that change the disease’s natural history. This concept was introduced in 2001 with all stages ascribed the diagnosis of heart failure, which was perhaps an overreach. For 2005, we changed the nomenclature so that stages A and B are now grouped under the heading that says “pre-heart failure or at risk for heart failure,” and C and D represent “heart failure.”
Just as when we talk about risk factors for ischemic heart disease, we’re trying to get practitioners to think in that same sort of seamless context with heart failure. So if you’re a hospitalist admitting a patient with uncontrolled hypertension, not only should the target of therapy be getting blood pressure under control.
You should also be aware that by getting blood pressure under control, putting the patient on an appropriate multidrug regimen and working with the outpatient system, you are in effect anticipating heart failure and beginning to treat it accordingly. Such a model would truly represent the intent of these new guidelines.
These guidelines discuss device use in symptomatic failure, particularly the idea of giving implantable defibrillators and cardiac resynchronization therapy class I recommendation and transplantation a class III recommendation. Why is this important for hospitalists?
With the emergence of better therapies for heart failure ” drugs and devices “and with patients living longer with the disease, the natural history of treated heart failure is changing. Even the question of candidacy for transplantation has become a moving target. The current suite of therapies now incorporates not only lifesaving drug therapies, but also disease-altering device therapies.
Even though that doesn’t directly affect hospitalists, their patients increasingly will have devices in place. For example, hospitalists will need to consider device malfunction or sub-optimization as possibly contributing to persistent symptoms.
Just as we now talk about medication compliance, we will soon begin to have a language that asks if the patient’s device is doing what it’s supposed to do. And that will fall into the lap of hospitalists.
So, I think for hospitalists, it’s good news. The better news is that we have a great portfolio of drugs and devices to improve outcomes in heart failure, a renewed awareness of the continuum of risk and the necessity for earlier intervention, and the challenge to find a way to incorporate all the right strategies in a mix that most benefits our patients. I view that as a win-win for all.
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.