New guidelines help manage chronic heart failure

"More treatments have made our decision-making far more complex since the last ACC/AHA heart failure guidelines only four years ago," stated Sharon Ann Hunt, M.D., professor of cardiovascular medicine at Stanford University Medical Center and chair of the writing group.

"The updated guidelines identify four stages of the disease and provide for each stage targeted therapy, which can help decrease morbidity and mortality," said Solomon Aifuwa, R.Ph., at Muhlenberg Regional Medical Center in Plainfield, N.J.

Alwarshetty noted that the guidelines emphasize that early diagnosis and proper management of hypertension, atherosclerotic vascular disease, and diabetes in high-risk patients may help delay and avoid HF.

The experts recommend that most HF patients generally be treated with a combination of three types of drugs: a diuretic, an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB), and a beta-blocker (BB). "Based on compelling evidence from large-scale clinical studies, these drugs are regarded as the cornerstone for HF management," said Aifuwa.

There is no arguing that ACEIs are the standard of care for HF patients. But what options do clinicians have if the patient is unable to tolerate this drug class? ARBs are considered a reasonable alternative in the guidelines. Although experience with ARBs in the literature is not as extensive as that seen with ACEIs, ARBs have been shown to reduce morbidity and mortality in HF patients who are intolerant to ACEIs. In a study published in the Lancet in 2003, candesartan (Atacand, AstraZeneca), an ARB, improved outcomes in patients with preserved ejection fraction (EF) who were intolerant of ACEIs.

In citing the results of the African American Heart Failure Trial (A-HeFT), published in the New England Journal of Medicine in 2004, the guidelines also support the combined use of hydralazine and a nitrate for patients with low EF who are already taking an ACEI and beta-blocker for symptomatic HF and have persistent symptoms.

In A-HeFT, a fixed-dose combination of isosorbide dinitrate and hydralazine (BiDil, NitroMed) was shown to reduce the risk of death and rate of first hospitalization for HF in self-identified Black patients when taken with current standard therapy.

The updated HF guidelines are available on the ACC Web site, http://www.acc.org/ and the AHA Web site, http://www.americanheart.org/.