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Thursday 18th August, 2005
New heart failure guidelines released by the AHA and the ACC,
stress on early diagnosis and new treatments.
Early diagnosis and new treatments
can help battle heart failure -- a growing national problem that
causes 1 million hospital admissions each year, according to new
guidelines released today by the American College of Cardiology
(ACC) and the American Heart Association (AHA).
The document is available today on the Web sites of the ACC (www.acc.org)
and the AHA (www.americanheart.org)
and will be published in the Sept. 20, 2005, issues of the
Journal of the American College of Cardiology, and Circulation:
Journal of the American Heart Association along with the ACC/AHA
Clinical Performance Measures for Adults with Chronic Heart
Failure and the ACC/AHA Key Data Elements and Definitions for
Measuring Clinical Measurements and Outcomes of Patients with
Chronic Heart Failure.
Noting that new treatment approaches may also improve the
quality of life for patients, the authors classified
failure on a scale from risk factors to end-stage disease:
- Stages A and B are when patients lack early signs or
symptoms of heart failure, but are at risk because of risk
factors or heart abnormalities, which could include a change
in the shape or structure of the heart.
- Stage C denotes patients with current or past
failure symptoms such as shortness of breath.
- Stage D designates patients with refractory
failure who might be eligible for specialized advanced
treatment -- including cardiac transplantation -- or
compassionate end-of-life care such as hospice.
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Nearly any form of heart disease may ultimately lead to
failure. The guidelines stress that early recognition and proper
treatment of high blood pressure,
disease and other cardiovascular risk factors can help patients
delay or avoid heart failure.
The key to prevention is to get the risk factors under
control. For instance, studies have shown controlling
hypertension can reduce the incidence of
heart failure by 50
"More treatments have made our decision-making far more
complex since the last ACC/AHA
heart failure guidelines only
four years ago," said Sharon Ann Hunt, M.D., F.A.C.C., professor
of cardiovascular medicine at Stanford University Medical Center
and chair of the writing group.
From 1990-99, the number of people hospitalized with a
primary diagnosis of heart failure increased from 810,000 to
more than 1 million. This was due to the population aging and to
more people surviving heart attacks.
Heart failure mostly
affects the elderly, and more Medicare dollars are spent for
heart failure diagnosis and treatment than for any other
About 5 million U.S. residents are living with
and more than 550,000 people are diagnosed with the condition
each year. In 2005 the disease will cost an estimated $27.9
billion in direct and indirect health care expenses, the authors
Some people may not realize one of the main symptoms of
failure is becoming easily exhausted.
"We know there are many people walking around who think they
are just out of shape or that they are just getting older, or
that their ankles are swelling because it's hot," said co-author
Mariell Jessup, M.D., F.A.C.C., medical director of the
failure and cardiac transplantation program and professor of
medicine at the University of Pennsylvania Medical Center in
Philadelphia. "They don't appreciate that this may be due to
The guidelines also change the name of the condition from
congestive heart failure (CHF) to
heart failure (HF) to reflect
the broad spectrum of the disease. Congestion occurs when the
heart cannot efficiently pump or eject blood from its chambers.
This causes fluid build-up in the lungs and heart, resulting in
stiff, fluid-filled lungs and shortness of breath. The panel
dropped the word 'congestive' because people can have few or no
symptoms of congestion, and still have a severely abnormal heart
with symptoms of fatigue and exercise intolerance caused by poor
cardiac output, Jessup said.
FITS for fun - create spectacular pictures in minute. In
recent years, doctors have recognized that many people with
normal ejection fraction have
heart failure. This often occurs
because the heart pumps properly, but fails to fill adequately
with blood, a condition called
diastolic heart failure. These
patients rarely have been included in clinical trials of new
drugs and devices in the past, but they are the subjects of
several new, ongoing trials. These trials should help settle the
issue of whether their treatment should be the same as that for
patients with reduced ejection fraction.
"The second major point is that
heart failure does not go
away," Jessup said. "There are drugs that need to be used and
medical care that needs to be done on a regular basis."
The committee also recommended left ventricular assist
devices (LVADs) be considered as permanent or "destination"
therapy in selected patients.
LVADs are implanted mechanical devices that help pump blood
through the heart and can be used as a reasonable permanent
therapy in some end-stage
heart failure patients who are not
candidates for transplants, don't respond to standard treatment
and have a one-year survival outlook of less than 50 percent.
The devices, which recently received U.S. Food and Drug
Administration approval as permanent or "destination" therapy,
were first used as a temporary measure to keep patients alive
while awaiting a heart transplant. "It's going to be a whole new
era in treating heart failure," Jessup said. "Eventually, we'll
have portable artificial pumps that can take over the action of
- Expand the number of patients eligible for implantable
cardioverter-defibrillators (ICDs), devices implanted under
the skin that save lives by shocking chaotic heart rhythms
back into a healthy pattern. ***
- Provide information on end-of-life issues. Although
treatment advances can extend lives,
heart failure is often
fatal. The guidelines recommend that cardiologists broach
the subject of hospice care -- support and comfort for dying
patients and their families.
"There is a failure to recognize that end-stage
patients frequently come in and out of the hospital over and
over again and suffer a lot with really no impact on their
ultimate survival," Jessup said. "I think using hospice is a way
of improving the remaining days that these patients have.
Hospice can be a very positive experience for patients and their
She acknowledged that this represents a new role for many
"Cardiologists aren't used to talking about hospice. They are
more used to doing interventions. So it is a big shift," she
The guidelines also suggest that a new perspective on
treating end-stage heart failure could result in a smoother,
less stressful transition for patients and their families.
Co-authors and members of the Heart Failure Guidelines
Writing Committee: William T. Abraham, M.D., F.A.C.C.; Marshall
H. Chin, M.D., M.P.H.; Arthur M. Feldman, M.D., Ph.D. F.A.C.C.;
Gary S. Francis, M.D., F.A.C.C.; Theodore G. Ganiats, M.D.;
Marvin A. Konstam, M.D., F.A.C.C.; Donna M. Mancini, M.D.; Keith
Michl, M.D.; John A. Oates, M.D.; Peter S. Rahko, M.D., F.A.C.C.;
Marc A. Silver, M.D., F.A.C.C.; Lynne Warner Stevenson, M.D.,
F.A.C.C; and Clyde W. Yancy, M.D., F.A.C.C.
Other organizations that participated in the development of
the guidelines were the American Academy of Family Physicians,
the American College of Physicians, the American College of
Chest Physicians, the Heart Failure Society of America and the
International Society for Heart and Lung Transplantation.
*** Editor's note: The final version of these guidelines have
further expanded the number of patients who should be considered
for ICDs, by adding the recommendation that patients with
ishemic cardiomyopathy, functional class 1 with low ejection
fraction be considered for ICD placement (MADIT II trial).
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